Provider Demographics
NPI:1558678904
Name:WARREN, MARY R (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:WARREN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:KELLEHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:2590 W SENECA TPKE
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-9735
Mailing Address - Country:US
Mailing Address - Phone:315-673-4034
Mailing Address - Fax:
Practice Address - Street 1:2590 W SENECA TPKE
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-9735
Practice Address - Country:US
Practice Address - Phone:315-673-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001430-1225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics