Provider Demographics
NPI:1245413020
Name:MUTCHNIK, ILENE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:MUTCHNIK
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:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-1000
Mailing Address - Country:US
Mailing Address - Phone:575-537-4000
Mailing Address - Fax:575-537-3921
Practice Address - Street 1:900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-537-4000
Practice Address - Fax:575-537-3921
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1128225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ7036Medicaid