Healthcare Provider Details

I. General information

NPI: 1629244975
Provider Name (Legal Business Name): MARY GRACE LUCAS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 PARRISH ST
CANANDAIGUA NY
14424-1731
US

IV. Provider business mailing address

100 CLEAR SPRING TRL APT 102
FAIRPORT NY
14450-1071
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-6067
  • Fax: 585-396-6966
Mailing address:
  • Phone: 214-724-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number111293
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number010046-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: