Provider Demographics
NPI:1043545817
Name:VANDERWORP, MARY KATHRYN (OT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:VANDERWORP
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 1:6115 N 12TH ST
Mailing Address - Street 2:UNIT #3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1717
Mailing Address - Country:US
Mailing Address - Phone:602-993-4191
Mailing Address - Fax:
Practice Address - Street 1:6115 N 12TH ST
Practice Address - Street 2:UNIT #3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-1717
Practice Address - Country:US
Practice Address - Phone:602-993-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0409225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist