Provider Demographics
NPI:1609158344
Name:MCNALLY, MONICA (COTA/L/ LMT)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:COTA/L/ LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 HAMMOCK CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1754
Mailing Address - Country:US
Mailing Address - Phone:904-347-5036
Mailing Address - Fax:
Practice Address - Street 1:109 HAMMOCK CIR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-1754
Practice Address - Country:US
Practice Address - Phone:904-347-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA8030174400000X
FLMA7761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist