Provider Demographics
NPI:1033251764
Name:SUBRA, MARY (OT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SUBRA
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 1:191 PITTYPAT PL
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5554
Mailing Address - Country:US
Mailing Address - Phone:770-601-5044
Mailing Address - Fax:678-432-2834
Practice Address - Street 1:191 PITTYPAT PL
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5554
Practice Address - Country:US
Practice Address - Phone:770-601-5044
Practice Address - Fax:678-432-2834
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003817225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA634151927BMedicaid
GA061724926OtherTAX ID
GA634151927DMedicaid