Provider Demographics
NPI:1740230283
Name:ANDERSON, MARY RAVENEL (OTLR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RAVENEL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTLR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-402-1495
Mailing Address - Fax:843-402-1285
Practice Address - Street 1:1941 SAVAGE ROAD
Practice Address - Street 2:STE 300A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-402-1495
Practice Address - Fax:843-402-1285
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1753Medicaid
SCTH0691Medicaid
SCGP1753Medicaid
SC8702Medicare PIN