1811173990 NPI number — MRS. MARY MAI IWANENKO MS, OTR/L, ATP, SI/C

Table of content: MRS. MARY MAI IWANENKO MS, OTR/L, ATP, SI/C (NPI 1811173990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811173990 NPI number — MRS. MARY MAI IWANENKO MS, OTR/L, ATP, SI/C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IWANENKO
Provider First Name:
MARY
Provider Middle Name:
MAI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, OTR/L, ATP, SI/C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811173990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 S SHORE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACKAWANNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14218-1753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-362-9121
Provider Business Mailing Address Fax Number:
716-362-8989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-822-4781
Provider Business Practice Location Address Fax Number:
716-362-8989
Provider Enumeration Date:
01/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  006633-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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