MEDICARE: MS. MARY SARITHA RAJ 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	056007787	IL

General Provider Information

NPI Number	:	1730349366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY SARITHA RAJ OTR

Provider Business Mailing Address
First Line	:	102 S MULBERRY AVE
Second Line	:
City	:	MOUNT MORRIS
State	:	IL
Zip	:	61054-1365
Country	:	US
Telephone Number	:	815-483-3068
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 S MULBERRY AVE
Second Line	:
City	:	MOUNT MORRIS
State	:	IL
Zip	:	61054-1365
Country	:	US
Telephone Number	:	815-483-3068
Fax Number	:

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

Provider Enumeration Date	:	06/17/2008
Last Update Date	:	06/17/2008

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