Provider Demographics
NPI:1730412685
Name:MAST, GLORIA CANDACE (COTA)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:CANDACE
Last Name:MAST
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4036 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1365
Mailing Address - Country:US
Mailing Address - Phone:716-694-6939
Mailing Address - Fax:
Practice Address - Street 1:2005 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-1222
Practice Address - Country:US
Practice Address - Phone:716-694-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000200-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics