Provider Demographics
NPI:1053975888
Name:OTAKE, MEGUMI (OTR)
Entity type:Individual
Prefix:
First Name:MEGUMI
Middle Name:
Last Name:OTAKE
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:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:RIDERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21139-0680
Mailing Address - Country:US
Mailing Address - Phone:937-602-3501
Mailing Address - Fax:214-305-3399
Practice Address - Street 1:300 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-1300
Practice Address - Country:US
Practice Address - Phone:410-527-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD06030Medicaid