Provider Demographics
NPI:1326806589
Name:AVERY, MARY BLAKE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:MARY BLAKE
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SONNY LN
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-9219
Mailing Address - Country:US
Mailing Address - Phone:757-810-4458
Mailing Address - Fax:
Practice Address - Street 1:301 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4017
Practice Address - Country:US
Practice Address - Phone:757-810-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
VA0119010263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist