Provider Demographics
NPI:1174531370
Name:MEISMER, MARY A (OTR/L, CHT (NBCOT))
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MEISMER
Suffix:
Gender:F
Credentials:OTR/L, CHT (NBCOT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LN
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8111
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-661-8107
Practice Address - Street 1:1111 TRINITY LN
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8111
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-661-8107
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056000370225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.000370OtherSTATE LICENSE