Provider Demographics
NPI:1639583420
Name:TANNER, MARY BETH (OT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:TANNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 REFINERY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2111
Mailing Address - Country:US
Mailing Address - Phone:940-665-1921
Mailing Address - Fax:940-665-1922
Practice Address - Street 1:1907 REFINERY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2111
Practice Address - Country:US
Practice Address - Phone:940-665-1921
Practice Address - Fax:940-665-1922
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106742225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation