Provider Demographics
NPI:1710622741
Name:PRADO, MARY ELLEN (COTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:PRADO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 S WHEELING AVE APT 214
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6406
Mailing Address - Country:US
Mailing Address - Phone:918-851-5967
Mailing Address - Fax:
Practice Address - Street 1:5140 S WHEELING AVE APT 214
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6406
Practice Address - Country:US
Practice Address - Phone:918-851-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2417224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant