Provider Demographics
NPI:1144780529
Name:VANBROCKLIN, MARAYA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARAYA
Middle Name:LYNN
Last Name:VANBROCKLIN
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 1:810 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3304
Mailing Address - Country:US
Mailing Address - Phone:315-323-5463
Mailing Address - Fax:
Practice Address - Street 1:453 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1834
Practice Address - Country:US
Practice Address - Phone:315-836-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023373-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist