Provider Demographics
NPI:1730431180
Name:BOLAM, MARIANNE EILEEN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:EILEEN
Last Name:BOLAM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 NORVELL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6751
Mailing Address - Country:US
Mailing Address - Phone:941-276-5501
Mailing Address - Fax:
Practice Address - Street 1:1111 DRURY LN
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-4545
Practice Address - Country:US
Practice Address - Phone:941-474-0290
Practice Address - Fax:941-474-0696
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14388225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist