Provider Demographics
NPI:1356948988
Name:NEURODIVERSE OT, LLC
Entity type:Organization
Organization Name:NEURODIVERSE OT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MSOT, OTR/L
Authorized Official - Phone:505-239-4097
Mailing Address - Street 1:12121 RANCHITOS RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2320
Mailing Address - Country:US
Mailing Address - Phone:505-239-4097
Mailing Address - Fax:
Practice Address - Street 1:12121 RANCHITOS RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2320
Practice Address - Country:US
Practice Address - Phone:505-239-4097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326597634Medicaid