Basic Information
| Provider Information | |||||||||
| NPI: | 1992991889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELDER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 SW 19TH ST | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793603806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757065923 | ||||||||
| FaxNumber: | 4325231903 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SW 19TH ST | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793603806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757065923 | ||||||||
| FaxNumber: | 4325231903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1961 | NM | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 114224 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.