Provider Demographics
NPI:1871168575
Name:BODEN, MALLORY (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BODEN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130-5940
Mailing Address - Country:US
Mailing Address - Phone:440-371-3480
Mailing Address - Fax:
Practice Address - Street 1:5311 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-3800
Practice Address - Country:US
Practice Address - Phone:440-842-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT011427225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist