Provider Demographics
NPI:1740874452
Name:KEENE, MALLORY RAE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:RAE
Last Name:KEENE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 KYESLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:ME
Mailing Address - Zip Code:04239-4324
Mailing Address - Country:US
Mailing Address - Phone:207-931-5091
Mailing Address - Fax:
Practice Address - Street 1:17 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:ME
Practice Address - Zip Code:04346-5143
Practice Address - Country:US
Practice Address - Phone:207-588-2699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist