Provider Demographics
NPI:1114189339
Name:MIJANOVICH, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MIJANOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-1213
Mailing Address - Country:US
Mailing Address - Phone:360-426-1651
Mailing Address - Fax:360-426-4680
Practice Address - Street 1:1850 SE CRESCENT DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-8670
Practice Address - Country:US
Practice Address - Phone:360-868-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2008-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist