Provider Demographics
NPI:1619279130
Name:PETT, MIRIAM (OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:PETT
Suffix:
Gender:F
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 1:12 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3260
Mailing Address - Country:US
Mailing Address - Phone:978-283-0315
Mailing Address - Fax:978-283-2496
Practice Address - Street 1:12 BEACH RD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3260
Practice Address - Country:US
Practice Address - Phone:978-283-0315
Practice Address - Fax:978-283-2496
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-04
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH3449225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist