Provider Demographics
NPI:1073039236
Name:CARLL-BENNETT, ELLEN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:CARLL-BENNETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:45 BONNEY BRIAR DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-6206
Mailing Address - Country:US
Mailing Address - Phone:508-728-4619
Mailing Address - Fax:
Practice Address - Street 1:45 BONNEY BRIAR DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-6206
Practice Address - Country:US
Practice Address - Phone:508-728-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA60580357OtherAOTA
MA084213OtherNBCOT
MA2187OtherSTATE OF MASSACHUSETTS