Basic Information
| Provider Information | |||||||||
| NPI: | 1164493144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANRAVENHORST | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 ST. ANDREWS COURT | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073885437 | ||||||||
| FaxNumber: | 5073882108 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 ST. ANDREWS COURT | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073885437 | ||||||||
| FaxNumber: | 5073882108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 101743 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 15F11VA | 01 | MN | BCBS INDIV PROVIDER # | OTHER | 6411283 | 01 | MN | MEDICA INDIV PROVIDER # | OTHER |