Provider Demographics
NPI:1942638887
Name:GAGNON, MARLAYNA MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARLAYNA
Middle Name:MARIE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10958 E STATE ROAD 14
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:IN
Mailing Address - Zip Code:46910-9458
Mailing Address - Country:US
Mailing Address - Phone:574-505-0882
Mailing Address - Fax:
Practice Address - Street 1:9909 E 100 S
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-9163
Practice Address - Country:US
Practice Address - Phone:765-628-0605
Practice Address - Fax:765-628-3639
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002478A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant