Provider Demographics
NPI:1104586239
Name:JEONG, MARIE MIYEON (OTR)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:MIYEON
Last Name:JEONG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 HUNTER ST APT 339E
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4458
Mailing Address - Country:US
Mailing Address - Phone:914-886-8772
Mailing Address - Fax:
Practice Address - Street 1:4325 HUNTER ST APT 339E
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4458
Practice Address - Country:US
Practice Address - Phone:914-886-8772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026431225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist