Provider Demographics
NPI:1720219082
Name:MALYN, MARK (OT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MALYN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 CANDLEWYCK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-9426
Mailing Address - Country:US
Mailing Address - Phone:434-979-0987
Mailing Address - Fax:
Practice Address - Street 1:2005 CANDLEWYCK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-9426
Practice Address - Country:US
Practice Address - Phone:434-979-0987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001055225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist