Healthcare Provider Details

I. General information

NPI: 1114189339
Provider Name (Legal Business Name): MARY ANN MIJANOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2008
Last Update Date: 06/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SE CRESCENT DR
SHELTON WA
98584-8670
US

IV. Provider business mailing address

2430 N 13TH ST
SHELTON WA
98584-1213
US

V. Phone/Fax

Practice location:
  • Phone: 360-868-2024
  • Fax:
Mailing address:
  • Phone: 360-426-1651
  • Fax: 360-426-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00001926
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: