Provider Demographics
NPI:1306971999
Name:BESSENBACHER, MARY T
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BESSENBACHER
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 1:13015 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-2401
Mailing Address - Country:US
Mailing Address - Phone:816-316-5047
Mailing Address - Fax:816-316-5081
Practice Address - Street 1:GRANDVIEW C 4
Practice Address - Street 2:13015 10TH ST
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2401
Practice Address - Country:US
Practice Address - Phone:816-316-5047
Practice Address - Fax:816-316-5081
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003007904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO478777105Medicaid