Provider Demographics
NPI:1609011014
Name:KILGORE, MARY RUSSELL (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RUSSELL
Last Name:KILGORE
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 1:310 ODYSSEY DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-1646
Mailing Address - Country:US
Mailing Address - Phone:281-480-5648
Mailing Address - Fax:281-480-5691
Practice Address - Street 1:310 ODYSSEY DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-1646
Practice Address - Country:US
Practice Address - Phone:281-480-5648
Practice Address - Fax:281-480-5691
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-14
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100794225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics