Provider Demographics
NPI:1154524726
Name:NATHAN, MARY ELLEN (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:NATHAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:EMMI
Other - Middle Name:
Other - Last Name:NATHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:10800 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3043
Mailing Address - Country:US
Mailing Address - Phone:951-351-4652
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:951-351-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4002225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand