Provider Demographics
NPI:1639782386
Name:TREVISAN, MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:TREVISAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 NE TILLAMOOK ST APT 307
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5359
Mailing Address - Country:US
Mailing Address - Phone:208-596-8484
Mailing Address - Fax:
Practice Address - Street 1:4110 NE TILLAMOOK ST APT 307
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5359
Practice Address - Country:US
Practice Address - Phone:208-596-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR397332225XM0800X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health