Provider Demographics
NPI:1023158300
Name:POULIN, DANIELLE RENEA (OTRL)
Entity type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:RENEA
Last Name:POULIN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 W CARRILLO ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2252
Mailing Address - Country:US
Mailing Address - Phone:520-440-2641
Mailing Address - Fax:
Practice Address - Street 1:1601 N TUCSON BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3425
Practice Address - Country:US
Practice Address - Phone:520-325-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1879225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics