Provider Demographics
NPI:1972839538
Name:PEDERSEN, MARIANNE (OTR/L)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:PEDERSEN
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 1:8811 WARREN H ABERNATHY HWY
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301
Mailing Address - Country:US
Mailing Address - Phone:864-574-7282
Mailing Address - Fax:864-574-7664
Practice Address - Street 1:362 N PINE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1631
Practice Address - Country:US
Practice Address - Phone:864-398-5100
Practice Address - Fax:864-582-1996
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3406225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH2172Medicaid