MEDICARE: MS. MARY O'TOOLE WELLER O.T.R.

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	1962	CO

General Provider Information

NPI Number	:	1770806051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY O'TOOLE WELLER O.T.R.

Provider Business Mailing Address
First Line	:	3110 SPRINGRIDGE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3743
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 SPRINGRIDGE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3743
Country	:	US
Telephone Number	:	719-576-4610
Fax Number	:

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

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	03/01/2010

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