Provider Demographics
NPI:1437401395
Name:ROCKEFELLER, EVAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:ROCKEFELLER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-2075
Mailing Address - Country:US
Mailing Address - Phone:781-302-4600
Mailing Address - Fax:
Practice Address - Street 1:11 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2812
Practice Address - Country:US
Practice Address - Phone:617-889-2523
Practice Address - Fax:617-889-2524
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2015-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist