Provider Demographics
NPI:1417354259
Name:GOWER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 WEST PEACHTREE STREET. NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30044-1137
Mailing Address - Country:US
Mailing Address - Phone:404-602-4318
Mailing Address - Fax:404-607-0062
Practice Address - Street 1:739 WEST PEACHTREE STREET NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1137
Practice Address - Country:US
Practice Address - Phone:404-602-4318
Practice Address - Fax:404-607-0062
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006081225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-1168874Other58-1168874
GA1497893671OtherMEDICARE GRP7122