Provider Demographics
NPI:1093977860
Name:COOGAN, MARIALYCE D (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARIALYCE
Middle Name:D
Last Name:COOGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LIGHT FALLS DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5753
Mailing Address - Country:US
Mailing Address - Phone:919-529-0950
Mailing Address - Fax:
Practice Address - Street 1:7209 CREEDMOOR RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1625
Practice Address - Country:US
Practice Address - Phone:919-844-1100
Practice Address - Fax:919-844-1102
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2209225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist