Provider Demographics
NPI:1770151805
Name:MARSHALL, MIKKA GRACE (COTA/L)
Entity type:Individual
Prefix:
First Name:MIKKA
Middle Name:GRACE
Last Name:MARSHALL
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 1:7171 KECK PARK CIR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-6301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 PARKLANE ST
Practice Address - Street 2:
Practice Address - City:WALBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43465-1224
Practice Address - Country:US
Practice Address - Phone:419-545-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008008224Z00000X
OHOTA008008224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant