Provider Demographics
NPI:1760826440
Name:WELLESLEY PEDIATRIC OCCUPATIONAL THERAPY
Entity Type:Organization
Organization Name:WELLESLEY PEDIATRIC OCCUPATIONAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, OTR/L
Authorized Official - Phone:413-478-7019
Mailing Address - Street 1:65 WALNUT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2118
Mailing Address - Country:US
Mailing Address - Phone:413-478-7019
Mailing Address - Fax:
Practice Address - Street 1:65 WALNUT ST
Practice Address - Street 2:SUITE 302
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2118
Practice Address - Country:US
Practice Address - Phone:413-478-7019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8127225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69498Medicare PIN