Provider Demographics
NPI:1942686712
Name:VINCIGUERRA, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VINCIGUERRA
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 1:12124 HIGH TECH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-8373
Mailing Address - Country:US
Mailing Address - Phone:407-308-3912
Mailing Address - Fax:
Practice Address - Street 1:12124 HIGH TECH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8373
Practice Address - Country:US
Practice Address - Phone:407-308-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003180L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant