Provider Demographics
NPI:1366019093
Name:LASELLA, BETHANY MICHELLE (OTR)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:MICHELLE
Last Name:LASELLA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STILES RD
Mailing Address - Street 2:STE 203
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-4804
Mailing Address - Country:US
Mailing Address - Phone:855-390-7774
Mailing Address - Fax:855-734-4666
Practice Address - Street 1:209 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3501
Practice Address - Country:US
Practice Address - Phone:203-874-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5631225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist