Provider Demographics
NPI:1194022038
Name:PERSICO, SUSAN LYNN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:PERSICO
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 1:2495 MAIN STREET
Mailing Address - Street 2:234
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214
Mailing Address - Country:US
Mailing Address - Phone:716-836-5929
Mailing Address - Fax:
Practice Address - Street 1:2495 MAIN ST
Practice Address - Street 2:234
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2152
Practice Address - Country:US
Practice Address - Phone:716-836-5929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000122-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant