Healthcare Provider Details

I. General information

NPI: 1629411798
Provider Name (Legal Business Name): ALEXANDRA M GUDLEVICH MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 AMORY ST
JAMAICA PLAIN MA
02130-2652
US

IV. Provider business mailing address

555 AMORY ST
JAMAICA PLAIN MA
02130-2652
US

V. Phone/Fax

Practice location:
  • Phone: 401-998-0559
  • Fax:
Mailing address:
  • Phone: 401-998-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10830
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: