=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104056001
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARNI FERN ETENGOFF OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2009
-----------------------------------------------------
Last Update Date | 07/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13550 S JOG RD SUITE100
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-740-9811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3298 NW 62ND LANE
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-740-9811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT12612
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------