Provider Demographics
NPI:1124170618
Name:OECHSLIN, MARY JO
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:OECHSLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8832 N 65TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4386
Mailing Address - Country:US
Mailing Address - Phone:602-405-5759
Mailing Address - Fax:623-975-0874
Practice Address - Street 1:8832 N 65TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4386
Practice Address - Country:US
Practice Address - Phone:602-405-5759
Practice Address - Fax:623-975-0874
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ450982Medicaid