Provider Demographics
NPI:1649633488
Name:WHITE, MARY (OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3230
Mailing Address - Country:US
Mailing Address - Phone:405-410-4472
Mailing Address - Fax:
Practice Address - Street 1:2957 POPLAR DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3230
Practice Address - Country:US
Practice Address - Phone:405-410-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist