Provider Demographics
NPI:1043401649
Name:IWANICKI, BEVERLY (MSCASOTR/L)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:IWANICKI
Suffix:
Gender:F
Credentials:MSCASOTR/L
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:AGRELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3014
Mailing Address - Country:US
Mailing Address - Phone:197-877-7853
Mailing Address - Fax:
Practice Address - Street 1:6 CRANE ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3014
Practice Address - Country:US
Practice Address - Phone:197-877-7853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5205225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist