Provider Demographics
NPI:1043405327
Name:CAVISTON, MARY (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:CAVISTON
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 1:916 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2521
Mailing Address - Country:US
Mailing Address - Phone:605-343-8577
Mailing Address - Fax:
Practice Address - Street 1:916 MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2521
Practice Address - Country:US
Practice Address - Phone:605-343-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist