Provider Demographics
NPI:1669859070
Name:MARDER, MALLORY GABRIELLE (OTR)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:GABRIELLE
Last Name:MARDER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 LINDENMERE DR
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4312
Mailing Address - Country:US
Mailing Address - Phone:516-313-3476
Mailing Address - Fax:
Practice Address - Street 1:2384 LINDENMERE DR
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4312
Practice Address - Country:US
Practice Address - Phone:516-313-3476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist