Provider Demographics
NPI:1467702126
Name:VANESKO, MARY E (MOT, OTR-L, CIMI)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:E
Last Name:VANESKO
Suffix:
Gender:F
Credentials:MOT, OTR-L, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-0241
Mailing Address - Country:US
Mailing Address - Phone:570-336-0309
Mailing Address - Fax:272-207-2774
Practice Address - Street 1:311 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1620
Practice Address - Country:US
Practice Address - Phone:570-336-0309
Practice Address - Fax:272-207-2774
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
PAOC010598225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist