Basic Information
| Provider Information | |||||||||
| NPI: | 1639347453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORMBY | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 PAUL BRYANT DRIVE E | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053450192 | ||||||||
| FaxNumber: | 2052472194 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 PAUL BRYANT DRIVE E | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053450192 | ||||||||
| FaxNumber: | 2052472194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
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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 | 02501 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0019X | 2717 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.