Provider Demographics
NPI:1790373165
Name:MCCONNELL, MARY (COTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 HYLAN BLVD APT 2F
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2056
Mailing Address - Country:US
Mailing Address - Phone:917-744-0125
Mailing Address - Fax:
Practice Address - Street 1:59 HYLAN BLVD APT 2F
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2056
Practice Address - Country:US
Practice Address - Phone:917-744-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010624-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant