Provider Demographics
NPI:1649812686
Name:POLYAKOV, MARIANNE (OTR/L)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:POLYAKOV
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 BROCKET CT
Mailing Address - Street 2:
Mailing Address - City:JAMISON
Mailing Address - State:PA
Mailing Address - Zip Code:18929-1772
Mailing Address - Country:US
Mailing Address - Phone:215-834-5514
Mailing Address - Fax:
Practice Address - Street 1:2703 BROCKET CT
Practice Address - Street 2:
Practice Address - City:JAMISON
Practice Address - State:PA
Practice Address - Zip Code:18929-1772
Practice Address - Country:US
Practice Address - Phone:215-834-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010962225XG0600X, 225X00000X, 225XH1200X, 225XN1300X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation