Mallory Childress, COTA/L, B.I.S.

Primary specialty

Occupational Therapy AssistantTaxonomy code 224Z00000X

License

5379 Issued in AZ

Practice address

12550 W Palm LN
Avondale, AZ 85392-6594

Phone

(623) 824-2147

NPI assigned

Mar 18, 2015

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Mallory Waltenburg Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1426636800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1426636800000",
    "number": "1053705806",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12550 W PALM LN",
            "city": "AVONDALE",
            "state": "AZ",
            "postal_code": "853926594",
            "telephone_number": "623-824-2147"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12550 W PALM LN",
            "city": "AVONDALE",
            "state": "AZ",
            "postal_code": "853926594",
            "telephone_number": "623-824-2147"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CHILDRESS",
        "first_name": "MALLORY",
        "credential": "COTA/L, B.I.S.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-03-18",
        "last_updated": "2015-03-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "224Z00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapy Assistant",
            "state": "AZ",
            "license": "5379",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MALLORY",
            "last_name": "WALTENBURG",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Destiny Chavies
• Angel Chayrez, COTA/L
• Siri Che, PHARMACIST
• Sanford Martin Chesler, DPM
• Stephanie Chiel, LPC
• Diana Chisum, SLPA
• Rebecca Chmiel, LPC
• Stephanie Choate
• Dick Chopra, D.D.S
• Chow Counseling Family Services

• Occupational Therapy Assistant in Avondale, AZ
• Providers in Avondale, AZ by specialty
• Occupational Therapy Assistant in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.