Provider Demographics
NPI:1518370543
Name:MERNICK, MARA SHAWNA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARA
Middle Name:SHAWNA
Last Name:MERNICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4833
Mailing Address - Country:US
Mailing Address - Phone:917-208-8540
Mailing Address - Fax:
Practice Address - Street 1:704 EMPIRE AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4833
Practice Address - Country:US
Practice Address - Phone:917-208-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007265-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist