Healthcare Provider Details

I. General information

NPI: 1396768263
Provider Name (Legal Business Name): MARY WARREN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10233 W GREENFIELD AVE
MILWAUKEE WI
53214-3911
US

IV. Provider business mailing address

4036 N NEWHALL ST
SHOREWOOD WI
53211-1938
US

V. Phone/Fax

Practice location:
  • Phone: 414-791-0813
  • Fax:
Mailing address:
  • Phone: 414-964-7212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1410-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: