Provider Demographics
NPI:1609200286
Name:THRALL, MARY ELLEN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:THRALL
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 1:2615 11TH ST W
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-5493
Mailing Address - Country:US
Mailing Address - Phone:812-890-7795
Mailing Address - Fax:239-491-3057
Practice Address - Street 1:904 LEE BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4953
Practice Address - Country:US
Practice Address - Phone:239-674-9374
Practice Address - Fax:239-491-3057
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15931225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist