Provider Demographics
NPI:1164706123
Name:EHLE, MARY JO (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:EHLE
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 1:2611 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-7037
Mailing Address - Country:US
Mailing Address - Phone:608-362-2306
Mailing Address - Fax:
Practice Address - Street 1:2611 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-7037
Practice Address - Country:US
Practice Address - Phone:608-362-2306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.000769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist