Provider Demographics
NPI:1669522520
Name:BUETTNER, MARY ALICE (OTRL)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:BUETTNER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5009
Mailing Address - Country:US
Mailing Address - Phone:701-866-5344
Mailing Address - Fax:
Practice Address - Street 1:921 43RD AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-5320
Practice Address - Country:US
Practice Address - Phone:701-793-3646
Practice Address - Fax:701-293-6892
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND771225XP0200X
MN101102225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51413Medicaid