Provider Demographics
NPI:1083995989
Name:HERROLD, MARY DAVIDSON (OTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DAVIDSON
Last Name:HERROLD
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5143
Mailing Address - Country:US
Mailing Address - Phone:615-355-6767
Mailing Address - Fax:615-231-5072
Practice Address - Street 1:312 ANDOVER DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5143
Practice Address - Country:US
Practice Address - Phone:615-355-6767
Practice Address - Fax:615-231-5072
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN546224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant