Provider Demographics
NPI:1679727622
Name:SMITH, MARY ELLEN (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SMITH
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 1:165 ERNEST RD
Mailing Address - Street 2:
Mailing Address - City:STANFORDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12581-5907
Mailing Address - Country:US
Mailing Address - Phone:845-868-7278
Mailing Address - Fax:845-868-7278
Practice Address - Street 1:165 ERNEST RD
Practice Address - Street 2:
Practice Address - City:STANFORDVILLE
Practice Address - State:NY
Practice Address - Zip Code:12581-5907
Practice Address - Country:US
Practice Address - Phone:845-868-7278
Practice Address - Fax:845-868-7278
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004089-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics