Healthcare Provider Details

I. General information

NPI: 1659652345
Provider Name (Legal Business Name): THERESA LAURA BREEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CORDAGE PARK CIR
PLYMOUTH MA
02360-7322
US

IV. Provider business mailing address

91 OCEAN HILL DR
KINGSTON MA
02364-3006
US

V. Phone/Fax

Practice location:
  • Phone: 508-747-4720
  • Fax: 508-830-1078
Mailing address:
  • Phone: 508-259-9441
  • Fax: 508-830-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3479
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3479
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: