Healthcare Provider Details

I. General information

NPI: 1699943571
Provider Name (Legal Business Name): CARLA E. PROVOST OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 BOSTON RD
NORTH BILLERICA MA
01862-1034
US

IV. Provider business mailing address

467 PROSPECT ST UNIT 2
METHUEN MA
01844-7514
US

V. Phone/Fax

Practice location:
  • Phone: 978-667-2166
  • Fax:
Mailing address:
  • Phone: 978-886-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8622
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: