Healthcare Provider Details

I. General information

NPI: 1548711542
Provider Name (Legal Business Name): MRS. MARNIE HOFTIEZER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 11TH ST NE
WATERTOWN SD
57201-1833
US

IV. Provider business mailing address

1415 11TH AVE NE
WATERTOWN SD
57201-6711
US

V. Phone/Fax

Practice location:
  • Phone: 605-882-6355
  • Fax:
Mailing address:
  • Phone: 605-882-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0219
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: