Provider Demographics
NPI:1124508916
Name:PHILLIPS, MARYANN KIMBALL (COTA)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:KIMBALL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 VZ COUNTY ROAD 1803
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-3494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1638 VX CR 1803
Practice Address - Street 2:
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140
Practice Address - Country:US
Practice Address - Phone:903-962-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215295224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant