Provider Demographics
NPI:1881994341
Name:ACOSTA, MARY ELLEN ELIZABETH (OT)
Entity type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:ELIZABETH
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 TEAKETTLE SPOUT RD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-4237
Mailing Address - Country:US
Mailing Address - Phone:191-794-1037
Mailing Address - Fax:
Practice Address - Street 1:46 TEAKETTLE SPOUT RD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4237
Practice Address - Country:US
Practice Address - Phone:191-794-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006720-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics