Provider Demographics
NPI:1487207809
Name:PHANEUF, CHEYENNE ROSE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:ROSE
Last Name:PHANEUF
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 1:23 ROLLING GREEN DR APT K
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-7846
Mailing Address - Country:US
Mailing Address - Phone:508-496-6278
Mailing Address - Fax:
Practice Address - Street 1:10 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2900
Practice Address - Country:US
Practice Address - Phone:508-473-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4476224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant