Provider Demographics
NPI:1689839516
Name:ROPER, MARY CERISE (OT, CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CERISE
Last Name:ROPER
Suffix:
Gender:F
Credentials:OT, CHT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:CERISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT, CHT
Mailing Address - Street 1:274 HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:KEATCHIE
Mailing Address - State:LA
Mailing Address - Zip Code:71046-4900
Mailing Address - Country:US
Mailing Address - Phone:318-933-0077
Mailing Address - Fax:
Practice Address - Street 1:2906 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5851
Practice Address - Country:US
Practice Address - Phone:318-746-5295
Practice Address - Fax:318-746-5297
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10559225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A739C698Medicare PIN
LA3A739C749Medicare PIN