Provider Demographics
NPI:1114923133
Name:BASIAGO, MARLENE M (OTR/L,PT)
Entity Type:Individual
Prefix:MISS
First Name:MARLENE
Middle Name:M
Last Name:BASIAGO
Suffix:
Gender:F
Credentials:OTR/L,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 W LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:SUMMIT HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18250-1141
Mailing Address - Country:US
Mailing Address - Phone:570-645-4001
Mailing Address - Fax:570-645-4001
Practice Address - Street 1:39 W LUDLOW ST
Practice Address - Street 2:
Practice Address - City:SUMMIT HILL
Practice Address - State:PA
Practice Address - Zip Code:18250-1141
Practice Address - Country:US
Practice Address - Phone:570-645-4001
Practice Address - Fax:570-645-4001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA006324L225100000X
PAOC000061L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABA630050Medicare PIN
PA0130480001Medicare NSC
PABA629730Medicare PIN