Provider Demographics
NPI:1639386113
Name:SIMON, MARNO KAY (OTR)
Entity Type:Individual
Prefix:
First Name:MARNO
Middle Name:KAY
Last Name:SIMON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MARNO
Other - Middle Name:KAY
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:4266 WEST BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-971-8391
Mailing Address - Fax:
Practice Address - Street 1:4266 WEST BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-971-8391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist