Provider Demographics
NPI:1669507307
Name:DISILVESTRO, ANN BOUVIER (OTR L)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:BOUVIER
Last Name:DISILVESTRO
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 1:12622 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4408
Mailing Address - Country:US
Mailing Address - Phone:480-991-7334
Mailing Address - Fax:
Practice Address - Street 1:12622 N 60TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4408
Practice Address - Country:US
Practice Address - Phone:480-991-7334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0108OtherOCCP. THERAPY LICENSE