Provider Demographics
NPI:1922535624
Name:WITHERELL, BRIAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ELM ST
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:ME
Mailing Address - Zip Code:04239-1735
Mailing Address - Country:US
Mailing Address - Phone:681-209-4285
Mailing Address - Fax:
Practice Address - Street 1:15 STRAWBERRY AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5941
Practice Address - Country:US
Practice Address - Phone:207-777-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008369224Z00000X
WVC2059224Z00000X
MEOA4088224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant