Provider Demographics
NPI:1366201279
Name:MALLARI, AGNES KEZIA MONTEALTO (PT)
Entity type:Individual
Prefix:
First Name:AGNES KEZIA
Middle Name:MONTEALTO
Last Name:MALLARI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E 22ND
Mailing Address - Street 2:2174
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:929-736-7517
Mailing Address - Fax:
Practice Address - Street 1:2579 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4552
Practice Address - Country:US
Practice Address - Phone:929-736-7517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist