Provider Demographics
NPI:1558465690
Name:BALASUNDRAM, MARIE DEBORAH (OT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:DEBORAH
Last Name:BALASUNDRAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S MADDER DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-7954
Mailing Address - Country:US
Mailing Address - Phone:717-791-0513
Mailing Address - Fax:717-918-2020
Practice Address - Street 1:6 S MADDER DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-7954
Practice Address - Country:US
Practice Address - Phone:717-791-0513
Practice Address - Fax:717-918-2020
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC 008551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA148654Medicare PIN
PA148751ZC8RMedicare PIN
PA148751Medicare PIN