Provider Demographics
NPI:1972848927
Name:BANNING, MARY LOU L (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY LOU
Middle Name:L
Last Name:BANNING
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4411 MT PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-6547
Mailing Address - Country:US
Mailing Address - Phone:303-503-5739
Mailing Address - Fax:
Practice Address - Street 1:4411 MT PRINCETON ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-6547
Practice Address - Country:US
Practice Address - Phone:303-503-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAA265447224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant