Provider Demographics
NPI:1205844404
Name:BOESEWETTER, MARY LEE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARY LEE
Middle Name:
Last Name:BOESEWETTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 BOBBY LN
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1985
Mailing Address - Country:US
Mailing Address - Phone:440-808-9209
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5000 ROCKSIDE RD STE 500
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2178
Practice Address - Country:US
Practice Address - Phone:216-459-2846
Practice Address - Fax:216-901-2803
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT000492225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842995Medicaid
OH11576182OtherCAQH
OH000000217474OtherANTHEM BLUE CROSS AND BLU