Provider Demographics
NPI:1154642668
Name:ROSTER, MARILYN (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
Last Name:ROSTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5854 TROY VILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-2650
Mailing Address - Country:US
Mailing Address - Phone:937-470-1750
Mailing Address - Fax:
Practice Address - Street 1:5440 CHARLESGATE RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1049
Practice Address - Country:US
Practice Address - Phone:937-236-6707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.07103171W00000X
MI5502002750171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor