Provider Demographics
NPI:1891272597
Name:KIRSCH, MALLORY (DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KIRSCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11545 E RADISSON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6861
Mailing Address - Country:US
Mailing Address - Phone:618-316-3727
Mailing Address - Fax:
Practice Address - Street 1:11545 E RADISSON RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6861
Practice Address - Country:US
Practice Address - Phone:618-316-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60837937225100000X
SC9868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist