Provider Demographics
NPI:1306382387
Name:WHALEN, COLLEEN ANNE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:ANNE
Last Name:WHALEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:COLLEEN
Other - Middle Name:ANNE
Other - Last Name:SANDFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:171 INTREPID LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2548
Mailing Address - Country:US
Mailing Address - Phone:315-437-4689
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009654-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant