Provider Demographics
NPI:1295810083
Name:TRAIL, MARY SUSAN (OTRL)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:TRAIL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5027 STE RTE 36
Mailing Address - Street 2:
Mailing Address - City:CANISTEO
Mailing Address - State:NY
Mailing Address - Zip Code:14823
Mailing Address - Country:US
Mailing Address - Phone:607-698-2775
Mailing Address - Fax:607-776-9366
Practice Address - Street 1:6838 INDUSTRIAL PARK ROAD
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810
Practice Address - Country:US
Practice Address - Phone:607-776-0325
Practice Address - Fax:607-776-9366
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0072741225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist