Provider Demographics
NPI:1851432868
Name:FELLENZ, MARY LYNN (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:FELLENZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6593 AUTUMN WOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-7801
Mailing Address - Country:US
Mailing Address - Phone:239-641-2622
Mailing Address - Fax:239-594-7912
Practice Address - Street 1:5691 NAPLES BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2023
Practice Address - Country:US
Practice Address - Phone:239-592-6100
Practice Address - Fax:239-592-6156
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 7400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884324400Medicaid