MEDICARE: MARIAH PERKINS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	010935-1	NY

General Provider Information

NPI Number	:	1164581229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAH PERKINS OTRL

Provider Business Mailing Address
First Line	:	114 HIGH ST
Second Line	:
City	:	AVON
State	:	NY
Zip	:	14414-1006
Country	:	US
Telephone Number	:	585-924-3642
Fax Number	:	585-742-2559

Provider Business Practice Location Address
First Line	:	1235 STATE ROUTE 332
Second Line	:
City	:	FARMINGTON
State	:	NY
Zip	:	14425-1077
Country	:	US
Telephone Number	:	585-924-3642
Fax Number	:	585-742-2559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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