Provider Demographics
NPI:1114219029
Name:DEGRACIA, BRIDGET MARY (COTA)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:MARY
Last Name:DEGRACIA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 DEACON SMITH HILL RD
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:NY
Mailing Address - Zip Code:12563-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 ROUTE 6
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-7707
Practice Address - Country:US
Practice Address - Phone:917-584-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001073-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor