Provider Demographics
NPI:1245538156
Name:MICINOWSKI, MARY HELEN (COTA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:HELEN
Last Name:MICINOWSKI
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 1:49 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-3900
Mailing Address - Country:US
Mailing Address - Phone:845-313-6407
Mailing Address - Fax:
Practice Address - Street 1:49 BIRCHWOOD DR
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-3900
Practice Address - Country:US
Practice Address - Phone:845-313-6407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002951-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant