Healthcare Provider Details

I. General information

NPI: 1679969349
Provider Name (Legal Business Name): SLOAN LAZZARESCHI OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 HARTFORD AVE APT 5B
JOHNSTON RI
02919-7124
US

IV. Provider business mailing address

1139 HARTFORD AVE APT 5B
JOHNSTON RI
02919-7124
US

V. Phone/Fax

Practice location:
  • Phone: 401-623-6363
  • Fax:
Mailing address:
  • Phone: 401-623-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT01478
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: