Provider Demographics
NPI:1699277434
Name:BARDYGA, MARY ELLEN (OT)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:BARDYGA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6470 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48324-2006
Mailing Address - Country:US
Mailing Address - Phone:248-363-4121
Mailing Address - Fax:
Practice Address - Street 1:6470 ALDEN DR
Practice Address - Street 2:
Practice Address - City:ORCHARD LAKE
Practice Address - State:MI
Practice Address - Zip Code:48324-2006
Practice Address - Country:US
Practice Address - Phone:248-363-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003179225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist