Healthcare Provider Details

I. General information

NPI: 1699559096
Provider Name (Legal Business Name): BONNIE RAE PURCELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 E COLUMBUS AVE
SPRINGFIELD MA
01105-2509
US

IV. Provider business mailing address

329 NEIPSIC RD
GLASTONBURY CT
06033-3032
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-8329
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4875
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: