Provider Demographics
NPI:1053829341
Name:DEMISSIE, MYRA MARTHA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:MARTHA
Last Name:DEMISSIE
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 1:10714 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-2112
Mailing Address - Country:US
Mailing Address - Phone:240-542-4420
Mailing Address - Fax:
Practice Address - Street 1:10714 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-2112
Practice Address - Country:US
Practice Address - Phone:240-542-4420
Practice Address - Fax:240-542-4420
Is Sole Proprietor?:No
Enumeration Date:2018-01-20
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07952225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist