Provider Demographics
NPI:1639347453
Name:FORMBY, MARY (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FORMBY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 PAUL BRYANT DRIVE E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2055
Mailing Address - Country:US
Mailing Address - Phone:205-345-0192
Mailing Address - Fax:205-247-2194
Practice Address - Street 1:400 PAUL BRYANT DRIVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2009
Practice Address - Country:US
Practice Address - Phone:205-345-0192
Practice Address - Fax:205-247-2194
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02501225X00000X
AL2717225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist