Individual
MARY SUBRA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
191 PITTYPAT PL, MCDONOUGH, GA 30253-5554
(770) 601-5044
(678) 432-2834
Mailing address
191 PITTYPAT PL, MCDONOUGH, GA 30253-5554
(770) 601-5044
(678) 432-2834
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
003817
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
061724926
TAX ID
GA
05
—
634151927B
—
GA
05
—
634151927D
—
GA
Enumeration date
02/12/2007
Last updated
09/25/2012
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