Provider Demographics
NPI:1780838490
Name:WIJNEN, MARLY JOHANNA (OTR)
Entity Type:Individual
Prefix:
First Name:MARLY
Middle Name:JOHANNA
Last Name:WIJNEN
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 1:2465 BATHGATE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5928
Mailing Address - Country:US
Mailing Address - Phone:171-836-7591
Mailing Address - Fax:171-836-7669
Practice Address - Street 1:2465 BATHGATE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5928
Practice Address - Country:US
Practice Address - Phone:171-836-7591
Practice Address - Fax:171-836-7669
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005094-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist