Provider Demographics
NPI:1497580112
Name:MUNDY, MALLORY JO MAYE (COTA/L)
Entity type:Individual
Prefix:
First Name:MALLORY JO
Middle Name:MAYE
Last Name:MUNDY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 ROCKTON CIR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7602
Mailing Address - Country:US
Mailing Address - Phone:616-283-0564
Mailing Address - Fax:
Practice Address - Street 1:3300 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2810
Practice Address - Country:US
Practice Address - Phone:616-942-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202010211224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant