Provider Demographics
NPI:1710194089
Name:BOLLIVER, LAURA MARIE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:BOLLIVER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 SEAWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-3828
Mailing Address - Country:US
Mailing Address - Phone:631-765-2157
Mailing Address - Fax:
Practice Address - Street 1:365 SEAWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3828
Practice Address - Country:US
Practice Address - Phone:631-765-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007485-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist