Provider Demographics
NPI:1033390448
Name:AVERY, MARILYN JOYCE (OTA)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JOYCE
Last Name:AVERY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3224
Mailing Address - Country:US
Mailing Address - Phone:918-742-5991
Mailing Address - Fax:
Practice Address - Street 1:4300 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4519
Practice Address - Country:US
Practice Address - Phone:918-254-5000
Practice Address - Fax:918-250-2538
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK586224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant