Provider Demographics
NPI:1841731023
Name:SHOUSE, MARY (OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHOUSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 S 115TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7637
Mailing Address - Country:US
Mailing Address - Phone:623-628-7806
Mailing Address - Fax:
Practice Address - Street 1:2506 S 115TH LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7637
Practice Address - Country:US
Practice Address - Phone:623-628-7806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6933225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist