Provider Demographics
NPI:1659974731
Name:JAMES, MARY (COTA/L, LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:JAMES
Suffix:
Gender:F
Credentials:COTA/L, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 W IL ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-9352
Mailing Address - Country:US
Mailing Address - Phone:815-739-0793
Mailing Address - Fax:
Practice Address - Street 1:6778 MILL RD STE 300
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2502
Practice Address - Country:US
Practice Address - Phone:815-739-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021164225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist