Provider Demographics
NPI:1720117815
Name:OETTER, MARY LYN (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYN
Last Name:OETTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:PANAMA
Mailing Address - State:IA
Mailing Address - Zip Code:51562-0001
Mailing Address - Country:US
Mailing Address - Phone:712-254-9018
Mailing Address - Fax:712-254-9019
Practice Address - Street 1:101 E 22ND ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-2800
Practice Address - Country:US
Practice Address - Phone:712-254-9018
Practice Address - Fax:712-254-9019
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA051751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI0771Medicare ID - Type Unspecified