Provider Demographics
NPI:1316220486
Name:DIVITA, MARY CAROLYN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CAROLYN
Last Name:DIVITA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ANDOVER LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3365
Mailing Address - Country:US
Mailing Address - Phone:716-634-6702
Mailing Address - Fax:
Practice Address - Street 1:355 HARLEM RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1825
Practice Address - Country:US
Practice Address - Phone:716-821-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0037741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0037741OtherNYS LICENSE