=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720219082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MALYN OT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2009
-----------------------------------------------------
Last Update Date | 08/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 CANDLEWYCK DR
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-979-0987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 CANDLEWYCK DR
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-979-0987
-----------------------------------------------------
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 | 0119001055
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------