Provider Demographics
NPI:1538389804
Name:KISER, MARY NICOLE (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:NICOLE
Last Name:KISER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 LEGACY CIR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2378
Mailing Address - Country:US
Mailing Address - Phone:636-349-9089
Mailing Address - Fax:
Practice Address - Street 1:1520 LEGACY CIR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2378
Practice Address - Country:US
Practice Address - Phone:636-349-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015687225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist