Provider Demographics
NPI:1003092768
Name:BOUSQUET, DIANE E (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:E
Last Name:BOUSQUET
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BRICKSTONE SQ
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1437
Mailing Address - Country:US
Mailing Address - Phone:978-474-7500
Mailing Address - Fax:
Practice Address - Street 1:61 GREENWAY
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:VT
Practice Address - Zip Code:05354-9474
Practice Address - Country:US
Practice Address - Phone:802-254-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT073-0000049224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant