Provider Demographics
NPI:1073645057
Name:MARIK, THERESA MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:MARIK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3608
Mailing Address - Country:US
Mailing Address - Phone:573-647-6049
Mailing Address - Fax:
Practice Address - Street 1:1301 HWY 72
Practice Address - Street 2:SUITE 4
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4144
Practice Address - Country:US
Practice Address - Phone:573-647-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001270225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO471465401Medicaid