MEDICARE: MIA GRAYCE MASELLI OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5945	CT

General Provider Information

NPI Number	:	1447999727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA GRAYCE MASELLI OTR/L

Provider Business Mailing Address
First Line	:	350 CENTER ROCK GRN STE 10
Second Line	:
City	:	OXFORD
State	:	CT
Zip	:	06478-3170
Country	:	US
Telephone Number	:	203-828-6790
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 CENTER ROCK GRN
Second Line	:
City	:	OXFORD
State	:	CT
Zip	:	06478-3169
Country	:	US
Telephone Number	:	203-828-6790
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2022
Last Update Date	:	06/03/2022

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