Provider Demographics
NPI:1487254538
Name:PLANCHON, MARY ROSE (COTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:PLANCHON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9341D LIVINGSTON WAY
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-3106
Mailing Address - Country:US
Mailing Address - Phone:931-257-6129
Mailing Address - Fax:
Practice Address - Street 1:2040 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2296
Practice Address - Country:US
Practice Address - Phone:912-354-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002701224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant