Provider Demographics
NPI:1770797169
Name:DE PONTE, MARS VINE-HARDING (OCCUPATIONAL THERAPI)
Entity type:Individual
Prefix:
First Name:MARS
Middle Name:VINE-HARDING
Last Name:DE PONTE
Suffix:
Gender:M
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:MARS
Other - Middle Name:VINE-HARDING
Other - Last Name:DE PONTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1007 SE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2512
Mailing Address - Country:US
Mailing Address - Phone:206-240-5956
Mailing Address - Fax:
Practice Address - Street 1:1007 SE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2512
Practice Address - Country:US
Practice Address - Phone:206-240-5956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 00003150225X00000X
OR1035920225XP0019X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1035920OtherOCCUPATIONAL THERAPY LICENSE