Provider Demographics
NPI:1164558045
Name:OPITZ, MARY E
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:OPITZ
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 1:12263 E. HENRIE RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636
Mailing Address - Country:US
Mailing Address - Phone:307-234-8019
Mailing Address - Fax:307-266-4347
Practice Address - Street 1:12263 E HENRIE ROADWAY
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WY
Practice Address - Zip Code:82636-9611
Practice Address - Country:US
Practice Address - Phone:307-234-8019
Practice Address - Fax:307-266-4347
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services