Provider Demographics
NPI:1285680868
Name:WESLEY, MARY B (OTR/CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:WESLEY
Suffix:
Gender:F
Credentials:OTR/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:303 W MAIN ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-4832
Practice Address - Country:US
Practice Address - Phone:732-432-8900
Practice Address - Fax:732-431-0244
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00046400225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ094832PYAMedicare UPIN
NJ049454Medicare PIN