Provider Demographics
NPI:1982207775
Name:WILSON, LAUREN IVA-BENNETT (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:IVA-BENNETT
Last Name:WILSON
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 1:656 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:ME
Mailing Address - Zip Code:04217-7006
Mailing Address - Country:US
Mailing Address - Phone:207-754-2496
Mailing Address - Fax:
Practice Address - Street 1:175 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-4254
Practice Address - Country:US
Practice Address - Phone:207-777-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
OT3816225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist