Provider Demographics
NPI:1245273424
Name:EWALD, MARYLYNN (OT)
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:
Last Name:EWALD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3308
Mailing Address - Country:US
Mailing Address - Phone:989-497-6040
Mailing Address - Fax:989-497-6054
Practice Address - Street 1:3525 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3308
Practice Address - Country:US
Practice Address - Phone:989-497-6040
Practice Address - Fax:989-497-6054
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004634225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist