Healthcare Provider Details

I. General information

NPI: 1043783111
Provider Name (Legal Business Name): CARRIE MAHLE OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MAIN ST
FRUITLAND MD
21826-1663
US

IV. Provider business mailing address

4135 ELK CREEK DR
SALISBURY MD
21804-2557
US

V. Phone/Fax

Practice location:
  • Phone: 410-677-5805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number04388
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: