Provider Demographics
NPI:1154628394
Name:MARBLE, DENNILLE MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DENNILLE
Middle Name:MARIE
Last Name:MARBLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:DENNILLE
Other - Middle Name:MARIE
Other - Last Name:LANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:25 LIBERTY ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-3246
Mailing Address - Country:US
Mailing Address - Phone:585-343-1840
Mailing Address - Fax:
Practice Address - Street 1:25 LIBERTY ST STE 5
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3246
Practice Address - Country:US
Practice Address - Phone:585-343-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007610225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007610OtherPTA LICENSE NUMBER