Provider Demographics
NPI:1770811549
Name:MYNATT, ROSS T (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:T
Last Name:MYNATT
Suffix:
Gender:M
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 UPTOWN BLVD NE
Mailing Address - Street 2:360- WEST
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4214
Mailing Address - Country:US
Mailing Address - Phone:505-480-8972
Mailing Address - Fax:
Practice Address - Street 1:6400 UPTOWN BLVD NE
Practice Address - Street 2:360- WEST
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4214
Practice Address - Country:US
Practice Address - Phone:505-480-8972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-05
Last Update Date:2009-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist