MEDICARE: MRS. MARA MERVIUS MSORT/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	013454-1	NY

General Provider Information

NPI Number	:	1932295037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARA MERVIUS MSORT/L

Provider Business Mailing Address
First Line	:	111 EAST 59TH STREET
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6502
Country	:	US
Telephone Number	:	917-474-1172
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 EAST 59TH STREET
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6502
Country	:	US
Telephone Number	:	917-474-1172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	03/15/2011

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