Healthcare Provider Details

I. General information

NPI: 1730349366
Provider Name (Legal Business Name): MARY SARITHA RAJ OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S MULBERRY AVE
MOUNT MORRIS IL
61054-1365
US

IV. Provider business mailing address

102 S MULBERRY AVE
MOUNT MORRIS IL
61054-1365
US

V. Phone/Fax

Practice location:
  • Phone: 815-483-3068
  • Fax:
Mailing address:
  • Phone: 815-483-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056007787
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: