Healthcare Provider Details

I. General information

NPI: 1114675899
Provider Name (Legal Business Name): MAYLINE VERMULLEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 BOULEVARD OF THE AMERICAS
LAKEWOOD NJ
08701
US

IV. Provider business mailing address

211 BOULEVARD OF THE AMERICAS
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 215-550-1360
  • Fax:
Mailing address:
  • Phone: 215-550-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOC014988
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: