Healthcare Provider Details

I. General information

NPI: 1073660387
Provider Name (Legal Business Name): MARY'S PLACE PEDIATRIC REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9004 LINCOLN DR W STE F
MARLTON NJ
08053-3206
US

IV. Provider business mailing address

9004 LINCOLN DR W STE F
MARLTON NJ
08053-3206
US

V. Phone/Fax

Practice location:
  • Phone: 856-988-1160
  • Fax: 856-988-1183
Mailing address:
  • Phone: 856-988-1160
  • Fax: 856-988-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TARA MONTAGUE
Title or Position: PRESIDENT
Credential:
Phone: 856-988-1160