Healthcare Provider Details

I. General information

NPI: 1609011014
Provider Name (Legal Business Name): MARY RUSSELL KILGORE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2008
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 ODYSSEY DR
WEBSTER TX
77598-1646
US

IV. Provider business mailing address

310 ODYSSEY DR
WEBSTER TX
77598-1646
US

V. Phone/Fax

Practice location:
  • Phone: 281-480-5648
  • Fax: 281-480-5691
Mailing address:
  • Phone: 281-480-5648
  • Fax: 281-480-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number100794
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: