Healthcare Provider Details

I. General information

NPI: 1669656211
Provider Name (Legal Business Name): MARY JOAN BYRNE MOT OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 SOMERSET AVE
MEMPHIS TN
38104-6802
US

IV. Provider business mailing address

1415 SOMERSET AVE
MEMPHIS TN
38104-6802
US

V. Phone/Fax

Practice location:
  • Phone: 901-272-3141
  • Fax:
Mailing address:
  • Phone: 901-272-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT0000000158
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: