Provider Demographics
NPI:1427191113
Name:MCCARTHY, MARY MARTHA (MA OTRL)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARTHA
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:MA OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-4345
Mailing Address - Country:US
Mailing Address - Phone:307-259-2986
Mailing Address - Fax:307-237-6672
Practice Address - Street 1:350 W A ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1860
Practice Address - Country:US
Practice Address - Phone:307-237-4477
Practice Address - Fax:307-237-6672
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR 568225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314156OtherBLUE CROSS PROVIDER NUMBE