MEDICARE: MARY MAVERICK OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	12979	CA

General Provider Information

NPI Number	:	1215497821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MAVERICK OTR/L

Provider Business Mailing Address
First Line	:	357 S CURSON AVE APT 9K
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-5274
Country	:	US
Telephone Number	:	323-934-1076
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 N FAIRFAX AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-7207
Country	:	US
Telephone Number	:	714-646-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/20/2019

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