Healthcare Provider Details

I. General information

NPI: 1790035624
Provider Name (Legal Business Name): MARY ELIZABETH COLLIER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/04/2021
Certification Date: 09/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 LONE OAK DR
CADIZ KY
42211-6520
US

IV. Provider business mailing address

276 BARNETT RD
EDDYVILLE KY
42038-7516
US

V. Phone/Fax

Practice location:
  • Phone: 270-522-0488
  • Fax:
Mailing address:
  • Phone: 815-383-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.009706
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number133707
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: