Provider Demographics
NPI:1295285690
Name:SWENSON, MARY (COTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SWENSON
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 1:37 SILENT BROOK CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2610
Mailing Address - Country:US
Mailing Address - Phone:314-368-2906
Mailing Address - Fax:
Practice Address - Street 1:5400 EXECUTIVE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2594
Practice Address - Country:US
Practice Address - Phone:636-922-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016030987224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant