Provider Demographics
NPI:1396768263
Name:WARREN, MARY (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 N NEWHALL ST
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1938
Mailing Address - Country:US
Mailing Address - Phone:414-964-7212
Mailing Address - Fax:
Practice Address - Street 1:10233 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3911
Practice Address - Country:US
Practice Address - Phone:414-791-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1410-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist