Healthcare Provider Details

I. General information

NPI: 1992991889
Provider Name (Legal Business Name): MARY ELLEN ELDER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SW 19TH ST
SEMINOLE TX
79360-3806
US

IV. Provider business mailing address

500 SW 19TH ST
SEMINOLE TX
79360-3806
US

V. Phone/Fax

Practice location:
  • Phone: 575-706-5923
  • Fax: 432-523-1903
Mailing address:
  • Phone: 575-706-5923
  • Fax: 432-523-1903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1961
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number114224
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: