Provider Demographics
NPI:1831770882
Name:BORJA, MARK OLIVER VICERRA (OTR/L)
Entity type:Individual
Prefix:
First Name:MARK OLIVER
Middle Name:VICERRA
Last Name:BORJA
Suffix:
Gender:M
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 1:3632 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-1890
Mailing Address - Country:US
Mailing Address - Phone:410-382-8628
Mailing Address - Fax:
Practice Address - Street 1:700 W 40TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2140
Practice Address - Country:US
Practice Address - Phone:410-235-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09257225X00000X
MDA4265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant