Provider Demographics
NPI:1104056001
Name:ETENGOFF, MARNI FERN (OTR)
Entity type:Individual
Prefix:
First Name:MARNI
Middle Name:FERN
Last Name:ETENGOFF
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MARNI
Other - Middle Name:FERN
Other - Last Name:ETENGOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3298 NW 62ND LANE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496
Mailing Address - Country:US
Mailing Address - Phone:954-740-9811
Mailing Address - Fax:
Practice Address - Street 1:13550 S JOG RD
Practice Address - Street 2:SUITE100
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-1585
Practice Address - Country:US
Practice Address - Phone:954-740-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-26
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist