Provider Demographics
NPI:1760028948
Name:GOETTL, MALLORY OSBORNE (MS OTR/L)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:OSBORNE
Last Name:GOETTL
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FARRIS PARKS BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 FARRIS PARKS BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7650
Practice Address - Country:US
Practice Address - Phone:859-353-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY260897225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty