Provider Demographics
NPI:1093583007
Name:MARIOTT, TY R
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:R
Last Name:MARIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SPAULDING RD
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-9402
Mailing Address - Country:US
Mailing Address - Phone:405-380-6609
Mailing Address - Fax:
Practice Address - Street 1:1 E CLARK BASS BLVD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4209
Practice Address - Country:US
Practice Address - Phone:918-426-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant