Provider Demographics
NPI:1265667273
Name:MARRIOTT-FOWLER, JUDY LYNN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:LYNN
Last Name:MARRIOTT-FOWLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 BROADWAY
Mailing Address - Street 2:SUITE 510
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1231
Mailing Address - Country:US
Mailing Address - Phone:917-297-8169
Mailing Address - Fax:
Practice Address - Street 1:873 BROADWAY
Practice Address - Street 2:SUITE 510
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1231
Practice Address - Country:US
Practice Address - Phone:212-253-9383
Practice Address - Fax:212-253-5713
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019267-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist