Provider Demographics
NPI:1033532866
Name:QUALLS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:QUALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 685
Mailing Address - Street 2:1101 N. MAGNOLIA ST.
Mailing Address - City:WISTER
Mailing Address - State:OK
Mailing Address - Zip Code:74966-0685
Mailing Address - Country:US
Mailing Address - Phone:918-647-6766
Mailing Address - Fax:
Practice Address - Street 1:1101 N. MAGNOLIA ST.
Practice Address - Street 2:
Practice Address - City:WISTER
Practice Address - State:OK
Practice Address - Zip Code:74966
Practice Address - Country:US
Practice Address - Phone:918-647-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor