Provider Demographics
NPI:1669162228
Name:DYNIS, MARY (COTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DYNIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 W TROPICANA AVE UNIT 1134
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8189
Mailing Address - Country:US
Mailing Address - Phone:262-442-8387
Mailing Address - Fax:
Practice Address - Street 1:6345 S JONES BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3334
Practice Address - Country:US
Practice Address - Phone:702-515-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-2805224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant