Healthcare Provider Details

I. General information

NPI: 1902241714
Provider Name (Legal Business Name): LARA DUBOIS OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BAYSIDE RD # 109
GREENLAND NH
03840-2117
US

IV. Provider business mailing address

1 BAYSIDE RD # 109
GREENLAND NH
03840-2117
US

V. Phone/Fax

Practice location:
  • Phone: 603-373-0014
  • Fax: 603-433-6787
Mailing address:
  • Phone: 603-373-0014
  • Fax: 603-433-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1118
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: