Healthcare Provider Details

I. General information

NPI: 1679744882
Provider Name (Legal Business Name): MARY LAURA RICKER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6608 HARRODS VIEW CIR
PROSPECT KY
40059-9421
US

IV. Provider business mailing address

6608 HARRODS VIEW CIR
PROSPECT KY
40059-9421
US

V. Phone/Fax

Practice location:
  • Phone: 317-490-2024
  • Fax:
Mailing address:
  • Phone: 317-490-2024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000646A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberKY-R5944
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201008592
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: