Provider Demographics
NPI:1891150025
Name:ST JOHN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ST JOHN
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 1:18 OVERLOOK AVE
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-2606
Mailing Address - Country:US
Mailing Address - Phone:646-594-4225
Mailing Address - Fax:
Practice Address - Street 1:18 OVERLOOK AVE
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-2606
Practice Address - Country:US
Practice Address - Phone:646-594-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008508-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant