Provider Demographics
NPI:1396223350
Name:ALICEA, MARYGRACE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:MARYGRACE
Middle Name:
Last Name:ALICEA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 GREYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-2428
Mailing Address - Country:US
Mailing Address - Phone:845-398-3937
Mailing Address - Fax:
Practice Address - Street 1:59 GREYWOOD DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-2428
Practice Address - Country:US
Practice Address - Phone:845-398-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009767-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty