Provider Demographics
NPI:1396306031
Name:TEALE, MARILYN (LYNN) G
Entity type:Individual
Prefix:
First Name:MARILYN (LYNN)
Middle Name:G
Last Name:TEALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PETERSBURG RD
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-4902
Mailing Address - Country:US
Mailing Address - Phone:845-473-0468
Mailing Address - Fax:845-625-1482
Practice Address - Street 1:1248 SUSSEX TPK
Practice Address - Street 2:UNIT B11
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-440-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2004AF2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2004AFOtherCERTIFICATION