Basic Information
| Provider Information | |||||||||
| NPI: | 1366653370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6772 LUTZ AVE NW | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446469341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308804354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7233 WHIPPLE AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304988200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA-00558 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.