Provider Demographics
NPI:1114068392
Name:ANDERSON, MARY KRISTINA (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KRISTINA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 CONWAY CIR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7305
Mailing Address - Country:US
Mailing Address - Phone:815-679-6052
Mailing Address - Fax:815-679-6429
Practice Address - Street 1:1626 CONWAY CIR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7305
Practice Address - Country:US
Practice Address - Phone:815-679-6052
Practice Address - Fax:815-679-6429
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics