Provider Demographics
NPI:1619966611
Name:O'CONNOR ETHIER, JOMARIE (OT)
Entity Type:Individual
Prefix:
First Name:JOMARIE
Middle Name:
Last Name:O'CONNOR ETHIER
Suffix:
Gender:F
Credentials:OT
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 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:648 PLANK RD STE 101
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2062
Practice Address - Country:US
Practice Address - Phone:518-268-4800
Practice Address - Fax:518-268-4888
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007657-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02251958Medicaid
NY02251958Medicaid
NYQ20332Medicare UPIN