Provider Demographics
NPI:1790035624
Name:COLLIER, MARY ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:COLLIER
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 1:276 BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-7516
Mailing Address - Country:US
Mailing Address - Phone:815-383-0520
Mailing Address - Fax:
Practice Address - Street 1:72 LONE OAK DR
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-6520
Practice Address - Country:US
Practice Address - Phone:270-522-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009706225X00000X
KY133707225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790035624Medicaid