MEDICARE: MS. MARY ELLEN BARDYGA OT

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	5201003179	MI

General Provider Information

NPI Number	:	1699277434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELLEN BARDYGA OT

Provider Business Mailing Address
First Line	:	6470 ALDEN DR
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-2006
Country	:	US
Telephone Number	:	248-363-4121
Fax Number	:

Provider Business Practice Location Address
First Line	:	6470 ALDEN DR
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-2006
Country	:	US
Telephone Number	:	248-363-4121
Fax Number	:

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

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/17/2018

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