Provider Demographics
NPI:1659593465
Name:VAN SANT, MARY C (OTL)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:VAN SANT
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:VAN SANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3756 E NICOLE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4227
Practice Address - Country:US
Practice Address - Phone:928-753-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0510225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist