Provider Demographics
NPI:1487834511
Name:GILBERTSON, MARY ELLA (OT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLA
Last Name:GILBERTSON
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 1:8901 LOWELL DR NE
Mailing Address - Street 2:LOWELL ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-4400
Mailing Address - Country:US
Mailing Address - Phone:505-857-0187
Mailing Address - Fax:
Practice Address - Street 1:8901 LOWELL DR NE
Practice Address - Street 2:LOWELL ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-4400
Practice Address - Country:US
Practice Address - Phone:505-857-0187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63405202Medicaid