Provider Demographics
NPI:1750331682
Name:PENACHO, ANDREA E (OTRL)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:PENACHO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:SEEKONK
Mailing Address - State:MA
Mailing Address - Zip Code:02771-5647
Mailing Address - Country:US
Mailing Address - Phone:401-484-4989
Mailing Address - Fax:
Practice Address - Street 1:721 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4430
Practice Address - Country:US
Practice Address - Phone:401-946-4250
Practice Address - Fax:401-275-5645
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT00513225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI408949OtherBLUECHIP RI IND. ID#
RI408949OtherBLUECHIP RI IND. ID#
RI1454350001Medicare NSC