Provider Demographics
NPI:1790116275
Name:MCDONALD, MARY (COTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCDONALD
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 1:4255 POLK RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-8056
Mailing Address - Country:US
Mailing Address - Phone:812-480-1363
Mailing Address - Fax:
Practice Address - Street 1:12110 BUSINESS BLVD
Practice Address - Street 2:SUITE 6 PMB 413
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7725
Practice Address - Country:US
Practice Address - Phone:907-317-9349
Practice Address - Fax:866-628-8601
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHY T 2675225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics