Provider Demographics
NPI:1760669816
Name:SURPRENANT, MARK JOSEPH (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:SURPRENANT
Suffix:
Gender:M
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 1:37 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-1501
Mailing Address - Country:US
Mailing Address - Phone:978-509-8698
Mailing Address - Fax:
Practice Address - Street 1:20 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:JAFFREY
Practice Address - State:NH
Practice Address - Zip Code:03452-6631
Practice Address - Country:US
Practice Address - Phone:603-532-8762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8454225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist