Provider Demographics
NPI:1912254129
Name:GAMMON, MARY ANNE (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:GAMMON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:GAMMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6301 SURFSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTNO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-1027
Mailing Address - Country:US
Mailing Address - Phone:530-220-2711
Mailing Address - Fax:916-706-2074
Practice Address - Street 1:6301 SURFSIDE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTNO
Practice Address - State:CA
Practice Address - Zip Code:95831-1027
Practice Address - Country:US
Practice Address - Phone:530-220-2711
Practice Address - Fax:916-706-2074
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist