Provider Demographics
NPI:1093831026
Name:BAUMGARTNER, MARY SUSAN (OT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSAN
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:BAUMGARTNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4372 52ND ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4237
Mailing Address - Country:US
Mailing Address - Phone:701-282-6622
Mailing Address - Fax:
Practice Address - Street 1:4372 52ND ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4237
Practice Address - Country:US
Practice Address - Phone:701-282-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND21225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics