MEDICARE: MS. MARY ELLEN THRALL 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	OT15931	FL

General Provider Information

NPI Number	:	1609200286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELLEN THRALL OTR/L

Provider Business Mailing Address
First Line	:	2615 11TH ST W
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33971-5493
Country	:	US
Telephone Number	:	812-890-7795
Fax Number	:	239-491-3057

Provider Business Practice Location Address
First Line	:	904 LEE BLVD
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-4953
Country	:	US
Telephone Number	:	239-674-9374
Fax Number	:	239-491-3057

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

Provider Enumeration Date	:	08/30/2013
Last Update Date	:	08/30/2013

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