Provider Demographics
NPI:1649942046
Name:MARTIN, MARALIE BECKER (COTA/L)
Entity type:Individual
Prefix:
First Name:MARALIE
Middle Name:BECKER
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4377 E CHEROKEE HTS
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8323
Mailing Address - Country:US
Mailing Address - Phone:208-520-0385
Mailing Address - Fax:
Practice Address - Street 1:4377 E CHEROKEE HTS
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-8323
Practice Address - Country:US
Practice Address - Phone:208-520-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1022224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant