Provider Demographics
NPI:1174733471
Name:MALLARD, CYNTHIA LYN (DT)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYN
Last Name:MALLARD
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CHEBANSE
Mailing Address - State:IL
Mailing Address - Zip Code:60922-9778
Mailing Address - Country:US
Mailing Address - Phone:815-697-2114
Mailing Address - Fax:815-697-2640
Practice Address - Street 1:279 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:CHEBANSE
Practice Address - State:IL
Practice Address - Zip Code:60922-9778
Practice Address - Country:US
Practice Address - Phone:815-697-2114
Practice Address - Fax:815-697-2640
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist