MEDICARE: MARY COMBERIATE

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	225XP0200X	Pediatric Occupational Therapist	OT17394	FL

General Provider Information

NPI Number	:	1225579931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY COMBERIATE

Provider Business Mailing Address
First Line	:	1771 BAPTIST CLAY DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-8501
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1771 BAPTIST CLAY DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-8501
Country	:	US
Telephone Number	:	904-516-1800
Fax Number	:

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

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	01/04/2023

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