Provider Demographics
NPI:1851617542
Name:PECCIA, MARY ELLEN (MT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:PECCIA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 BELL BLVD
Mailing Address - Street 2:C/O NELIDA
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2043
Mailing Address - Country:US
Mailing Address - Phone:917-841-6715
Mailing Address - Fax:
Practice Address - Street 1:3915 BELL BLVD
Practice Address - Street 2:C/O NELIDA
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2043
Practice Address - Country:US
Practice Address - Phone:917-841-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004155-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist