Provider Demographics
NPI:1417960899
Name:SCHMIDT, MARY A (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:SCHMIDT
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 6195
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-6195
Mailing Address - Country:US
Mailing Address - Phone:208-238-3270
Mailing Address - Fax:208-904-2760
Practice Address - Street 1:2010 FLANDRO DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-1947
Practice Address - Country:US
Practice Address - Phone:208-238-3270
Practice Address - Fax:208-238-3270
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-240225X00000X
ID225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist