Provider Demographics
NPI:1053829341
Name:DEMISSIE, MYRA MARTHA (OTR/L)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:MARTHA
Last Name:DEMISSIE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 COLCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5902
Mailing Address - Country:US
Mailing Address - Phone:206-330-1797
Mailing Address - Fax:
Practice Address - Street 1:2401 NW 23RD ST STE 1C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2420
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-20
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-04253225X00000X
DCOT010001546225X00000X
VA0119010519225X00000X
OK5664225X00000X
MD07952225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist