Provider Demographics
NPI:1104284538
Name:MAHAN, DANA MICHELLE (COTA)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:MICHELLE
Last Name:MAHAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:DANA
Other - Middle Name:MICHELLE
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:22 MIDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-5348
Mailing Address - Country:US
Mailing Address - Phone:631-835-6482
Mailing Address - Fax:
Practice Address - Street 1:72 S WOODS RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1024
Practice Address - Country:US
Practice Address - Phone:516-921-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY64008779225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist