Provider Demographics
NPI:1366711301
Name:WHITE, LYNN MARIE (OTR/L PTA)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:OTR/L PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W CLARK ST
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-1101
Mailing Address - Country:US
Mailing Address - Phone:315-360-6241
Mailing Address - Fax:
Practice Address - Street 1:255 GROS BLVD
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1455
Practice Address - Country:US
Practice Address - Phone:315-866-8562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007498-1225200000X
NY011270-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant