Provider Demographics
NPI:1649750472
Name:STANDARD, MARY KATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:STANDARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6246
Mailing Address - Country:US
Mailing Address - Phone:706-364-6172
Mailing Address - Fax:706-262-2893
Practice Address - Street 1:2315 CENTRAL AVE STE C
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6246
Practice Address - Country:US
Practice Address - Phone:706-364-6172
Practice Address - Fax:706-262-2893
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty