Provider Demographics
NPI:1114322609
Name:ROMACK, MARK (OTR)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROMACK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5034 GREEN LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24589-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5034 GREEN LEVEL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:VA
Practice Address - Zip Code:24589-3044
Practice Address - Country:US
Practice Address - Phone:434-579-4682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004981225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist