Provider Demographics
NPI:1609277789
Name:ADVANCED OT OF BOSTON
Entity Type:Organization
Organization Name:ADVANCED OT OF BOSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HANNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:310-433-4245
Mailing Address - Street 1:167 M ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4258
Mailing Address - Country:US
Mailing Address - Phone:310-433-4245
Mailing Address - Fax:
Practice Address - Street 1:167 M ST APT 1F
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4258
Practice Address - Country:US
Practice Address - Phone:310-433-4245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10773225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty