Provider Demographics
NPI:1285838490
Name:BOLGER, MARY ELIZABETH (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:BOLGER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:REUSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 SPERTI DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-9654
Mailing Address - Country:US
Mailing Address - Phone:859-344-9322
Mailing Address - Fax:859-344-9332
Practice Address - Street 1:2003 PIECK DR
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41011-2627
Practice Address - Country:US
Practice Address - Phone:859-653-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2141171W00000X
KYR2141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100335270Medicaid