Provider Demographics
NPI:1194131938
Name:EBLACKER, MARY (OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EBLACKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL AVE
Mailing Address - Street 2:APT 76B
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-5613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 CENTRAL AVE
Practice Address - Street 2:APT 76B
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-5613
Practice Address - Country:US
Practice Address - Phone:484-883-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00652200225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist