Provider Demographics
NPI:1184224800
Name:MCCLINTON, MARIAH ASHLEY
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ASHLEY
Last Name:MCCLINTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 TIBER AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-7012
Mailing Address - Country:US
Mailing Address - Phone:401-999-0737
Mailing Address - Fax:
Practice Address - Street 1:6800 JERICHO TPKE STE 120W
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4445
Practice Address - Country:US
Practice Address - Phone:516-393-5966
Practice Address - Fax:800-783-5909
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025104225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty