Provider Demographics
NPI:1689635674
Name:WOODBURY, MARY L (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:LEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:324 GANNETT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3270
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:690 MINOT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-783-1328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT421225XH1200X
MO2005032058225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
171917YZWOtherDC MEDICARE PTAN
DC46950024OtherBCBS NCA PROVIDER #
MO266642Medicare ID - Type Unspecified