Provider Demographics
NPI:1558793695
Name:RADFORD, ELLEN JULIA (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:JULIA
Last Name:RADFORD
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:JULIA
Other - Last Name:SKLAROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:76A BROOKINGS ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5407
Mailing Address - Country:US
Mailing Address - Phone:617-650-5729
Mailing Address - Fax:
Practice Address - Street 1:76A BROOKINGS ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5407
Practice Address - Country:US
Practice Address - Phone:617-650-5729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10510225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
290947OtherNBCOT
MA10510OtherDIVISION OF PROFESSIONAL LICENSURE BOARD OF ALLIED HEALTH PROFESSIONS