Provider Demographics
NPI:1346394004
Name:PESANTEZ, MARIANA L (MS, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:MARIANA
Middle Name:L
Last Name:PESANTEZ
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 1:2675 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-748-0516
Mailing Address - Fax:980-389-0044
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-748-0516
Practice Address - Fax:980-389-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6246225X00000X
NY015089-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211258Medicaid
NC7301953Medicaid