Healthcare Provider Details

I. General information

NPI: 1144466939
Provider Name (Legal Business Name): MARIBETH MACKINNON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2008
Last Update Date: 12/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2387 STATE ROUTE 22
PERU NY
12972-4973
US

IV. Provider business mailing address

2387 STATE ROUTE 22
PERU NY
12972-4973
US

V. Phone/Fax

Practice location:
  • Phone: 518-569-1523
  • Fax:
Mailing address:
  • Phone: 518-569-1523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number005771-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: