MEDICARE: MARY ELISE TRENTHAM OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	111701	TX

General Provider Information

NPI Number	:	1699899948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELISE TRENTHAM OTR

Provider Business Mailing Address
First Line	:	4607 MANCHACA RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1607
Country	:	US
Telephone Number	:	512-916-1511
Fax Number	:	512-916-1532

Provider Business Practice Location Address
First Line	:	4607 MANCHACA RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1607
Country	:	US
Telephone Number	:	512-916-1511
Fax Number	:	512-916-1532

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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