Provider Demographics
NPI:1932347259
Name:ROTH-WYRICK, MARY ANN (OT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:ROTH-WYRICK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SGT PRENTISS DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4782
Mailing Address - Country:US
Mailing Address - Phone:601-446-8764
Mailing Address - Fax:601-446-8745
Practice Address - Street 1:55 SERGEANT PRENTISS DR
Practice Address - Street 2:SUITE 8
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4782
Practice Address - Country:US
Practice Address - Phone:601-446-8764
Practice Address - Fax:601-446-8745
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2374225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist