=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255889390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAUREEN MCGRADE COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2016
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 379 MT HOPE RD
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-7135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-344-2292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 SECOND ST
-----------------------------------------------------
City | CORNWALL ON HUDSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12520-1312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-270-3656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 009051-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------