Provider Demographics
NPI:1538317425
Name:ANTHONISEN, MARGOT L (OTRL)
Entity Type:Individual
Prefix:
First Name:MARGOT
Middle Name:L
Last Name:ANTHONISEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 LAKESIDE AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1132
Mailing Address - Country:US
Mailing Address - Phone:216-344-1565
Mailing Address - Fax:216-464-7342
Practice Address - Street 1:4255 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HILLS
Practice Address - State:OH
Practice Address - Zip Code:44128-2811
Practice Address - Country:US
Practice Address - Phone:216-292-9700
Practice Address - Fax:216-378-4613
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH007071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0028740Medicaid
OH0028740Medicaid