=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760826440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLESLEY PEDIATRIC OCCUPATIONAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2013
-----------------------------------------------------
Last Update Date | 04/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 WALNUT ST SUITE 302
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-478-7019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 WALNUT ST SUITE 302
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-478-7019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | JACLYN SANSONE
-----------------------------------------------------
Credential | M.ED., OTR/L
-----------------------------------------------------
Telephone | 413-478-7019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 8127
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------