Healthcare Provider Details

I. General information

NPI: 1205068657
Provider Name (Legal Business Name): MARY CATHERINE CUNNINGHAM-PORTNER MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 EXECUTIVE PARK DR SUITE 3
WESTON FL
33331-3634
US

IV. Provider business mailing address

2625 EXECUTIVE PARK DR SUITE 3
WESTON FL
33331-3634
US

V. Phone/Fax

Practice location:
  • Phone: 954-385-4696
  • Fax: 954-385-8385
Mailing address:
  • Phone: 954-385-4696
  • Fax: 954-385-8385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT11830
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT11830
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License NumberOT11830
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License NumberOT11830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: