Provider Demographics
NPI:1750306205
Name:VIGNERI, MARY R (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:VIGNERI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 BAINBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-8245
Mailing Address - Country:US
Mailing Address - Phone:706-833-6686
Mailing Address - Fax:
Practice Address - Street 1:223 BAINBRIDGE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8245
Practice Address - Country:US
Practice Address - Phone:706-833-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1413225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0641Medicaid