Provider Demographics
NPI:1326513680
Name:BANZON, MARYLEE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MARYLEE
Middle Name:
Last Name:BANZON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 GARIBALDI DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-7088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29516 KOHOUTEK WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1221
Practice Address - Country:US
Practice Address - Phone:510-441-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16033225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics