Provider Demographics
NPI:1316922552
Name:NORDGULEN, MARY ELIZABETH (OTR/L, C4T)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:NORDGULEN
Suffix:
Gender:F
Credentials:OTR/L, C4T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER ROAD
Mailing Address - Street 2:96TH MDG
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542
Mailing Address - Country:US
Mailing Address - Phone:850-883-8314
Mailing Address - Fax:334-836-2247
Practice Address - Street 1:307 BOATNER ROAD
Practice Address - Street 2:96TH MDG
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8314
Practice Address - Fax:334-836-2247
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2098225X00000X
FLOT1844225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891009320Medicaid
AL891009330Medicaid
AL891009340Medicaid