Provider Demographics
NPI:1306558812
Name:LLEWELLYN, MAUREEN LYN
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:LYN
Last Name:LLEWELLYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:LYN
Other - Last Name:PETRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 W DOMINICK ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W DOMINICK ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5846
Practice Address - Country:US
Practice Address - Phone:315-339-6536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013929-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist