Provider Demographics
NPI:1821114851
Name:MARBAN, GAYLE (OTRL)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:MARBAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 231225
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-1225
Mailing Address - Country:US
Mailing Address - Phone:907-222-7969
Mailing Address - Fax:
Practice Address - Street 1:1301 E DOWLING RD
Practice Address - Street 2:SUITE 106
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1436
Practice Address - Country:US
Practice Address - Phone:907-227-8935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1244225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT1244Medicaid