Provider Demographics
NPI:1699753095
Name:FAJER, MARY Y (PT OCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:Y
Last Name:FAJER
Suffix:
Gender:F
Credentials:PT OCS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:Y
Other - Last Name:O DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12686
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-0686
Mailing Address - Country:US
Mailing Address - Phone:503-540-8701
Mailing Address - Fax:503-371-8772
Practice Address - Street 1:4677 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1901
Practice Address - Country:US
Practice Address - Phone:503-585-5131
Practice Address - Fax:503-585-4065
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR207105Medicaid
OR207105Medicaid