Provider Demographics
NPI:1508925751
Name:WILLIAMS, MARY SARA (MA, OTR L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SARA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MA, OTR L
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SARA
Other - Last Name:MASUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, OTR L
Mailing Address - Street 1:1800 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4306
Mailing Address - Country:US
Mailing Address - Phone:612-789-1236
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4306
Practice Address - Country:US
Practice Address - Phone:612-789-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4494225X00000X
MN103361225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
391584408OtherTRICARE
WI41041200Medicaid
HP70878OtherHEALTH PARTNERS
167861OtherAETNA
6406809OtherMEDICA
MN434L1WIOtherBCBS MN
641671046996OtherPREFERRED ONE