Provider Demographics
NPI:1487681029
Name:PIECHOTA, MARY AGNES (AT,C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:AGNES
Last Name:PIECHOTA
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 3196
Mailing Address - Street 2:BLUE RIDGE ROAD
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-9631
Mailing Address - Country:US
Mailing Address - Phone:610-381-7246
Mailing Address - Fax:570-839-0974
Practice Address - Street 1:POCONO MOUNTAIN WEST HIGHSCHOOL
Practice Address - Street 2:HC 89 BOX 2002 ROUTE 940
Practice Address - City:POCONO SUMMITT, PA.
Practice Address - State:PA
Practice Address - Zip Code:18346
Practice Address - Country:US
Practice Address - Phone:570-839-7121
Practice Address - Fax:570-839-0974
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000295A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer