Basic Information
Provider Information | |||||||||
NPI: | 1255578829 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARINO | ||||||||
FirstName: | GERALDINE | ||||||||
MiddleName: | NOELIA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1714 E KIMSBROUGH RD | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840923855 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3477298540 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9361 S 300 E | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840702902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8018265000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2009 | ||||||||
LastUpdateDate: | 08/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 009659-1 | NY | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225XP0200X | 11437357-4201 | UT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.