Provider Demographics
NPI:1669559449
Name:DEATHERAGE, MARCY LYNETTE (OTR)
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:LYNETTE
Last Name:DEATHERAGE
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 1:16816 W 83RD TER
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-8072
Mailing Address - Country:US
Mailing Address - Phone:913-438-3372
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004189225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist