Provider Demographics
NPI:1821407891
Name:PINE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 PINE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-2157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 PINE ST APT 3
Practice Address - Street 2:
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-2157
Practice Address - Country:US
Practice Address - Phone:570-594-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP000791L314000000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility