MEDICARE: MARALIE BECKER MARTIN COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA-1022	ID

General Provider Information

NPI Number	:	1649942046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARALIE BECKER MARTIN COTA/L

Provider Business Mailing Address
First Line	:	4377 E CHEROKEE HTS
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83406-8323
Country	:	US
Telephone Number	:	208-520-0385
Fax Number	:

Provider Business Practice Location Address
First Line	:	4377 E CHEROKEE HTS
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83406-8323
Country	:	US
Telephone Number	:	208-520-0385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2021
Last Update Date	:	10/04/2021

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