Healthcare Provider Details

I. General information

NPI: 1811173990
Provider Name (Legal Business Name): MARY MAI IWANENKO MS, OTR/L, ATP, SI/C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 RIDGE RD
LACKAWANNA NY
14218-1755
US

IV. Provider business mailing address

219 S SHORE BLVD
LACKAWANNA NY
14218-1753
US

V. Phone/Fax

Practice location:
  • Phone: 716-822-4781
  • Fax: 716-362-8989
Mailing address:
  • Phone: 716-362-9121
  • Fax: 716-362-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number006633-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: