Provider Demographics
NPI:1023114691
Name:DAMICO, MARYANNE E (OTR)
Entity type:Individual
Prefix:MS
First Name:MARYANNE
Middle Name:E
Last Name:DAMICO
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 1:2608 W KENOSHA ST
Mailing Address - Street 2:SUITE 430
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8952
Mailing Address - Country:US
Mailing Address - Phone:918-259-3714
Mailing Address - Fax:
Practice Address - Street 1:2608 W KENOSHA ST
Practice Address - Street 2:SUITE 430
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8952
Practice Address - Country:US
Practice Address - Phone:918-259-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT 301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist