Provider Demographics
NPI:1285085787
Name:MIREILLE MARINO LOTR LLC
Entity type:Organization
Organization Name:MIREILLE MARINO LOTR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:MIREILLE
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, MA
Authorized Official - Phone:504-250-9553
Mailing Address - Street 1:4247 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-1907
Mailing Address - Country:US
Mailing Address - Phone:504-250-9553
Mailing Address - Fax:
Practice Address - Street 1:4247 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1907
Practice Address - Country:US
Practice Address - Phone:504-250-9553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-26
Last Update Date:2016-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA114059904OtherTYPE 1 NPI
LA1302686Medicaid