Provider Demographics
NPI:1679849947
Name:PANDARAKALAM, MARILYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:PANDARAKALAM
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 1:69 POPLAR ST
Mailing Address - Street 2:APT. GC
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1390
Mailing Address - Country:US
Mailing Address - Phone:917-575-7425
Mailing Address - Fax:
Practice Address - Street 1:37 HICKS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1354
Practice Address - Country:US
Practice Address - Phone:917-575-7425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011885-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist