Provider Demographics
NPI:1972938371
Name:HALLETT, MARK ANTHONY (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:HALLETT
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 1:419 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-4381
Mailing Address - Country:US
Mailing Address - Phone:401-339-8013
Mailing Address - Fax:
Practice Address - Street 1:600 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-739-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00645224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant