Provider Demographics
NPI:1124396114
Name:BASTIAN, MARILOU (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:
Last Name:BASTIAN
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 1:4492 NE OCEAN BLVD APT C1
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4354
Mailing Address - Country:US
Mailing Address - Phone:772-285-9957
Mailing Address - Fax:
Practice Address - Street 1:4492 NE OCEAN BLVD APT C1
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4354
Practice Address - Country:US
Practice Address - Phone:772-285-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9616225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics