Provider Demographics
NPI:1760014617
Name:PROVENCHER, MICHELLE ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:PROVENCHER
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 1:38 BUGBEE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-9707
Mailing Address - Country:US
Mailing Address - Phone:413-454-4146
Mailing Address - Fax:
Practice Address - Street 1:38 BUGBEE RD
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077-9707
Practice Address - Country:US
Practice Address - Phone:413-454-4146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5067225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty