Provider Demographics
NPI:1609651553
Name:GILL, MARY (COTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 OLD STAGECOACH LN
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2871 HIGHWAY 31 W
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-5226
Practice Address - Country:US
Practice Address - Phone:615-672-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant