Provider Demographics
NPI:1841451846
Name:ROSENTHAL, ELISSA C (OTRL)
Entity type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:C
Last Name:ROSENTHAL
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 1:443 MASSAPOAG AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-3014
Mailing Address - Country:US
Mailing Address - Phone:781-784-8182
Mailing Address - Fax:
Practice Address - Street 1:778 S MAIN ST
Practice Address - Street 2:UNIT 2 SHAWS PLAZA
Practice Address - City:SHARON
Practice Address - State:MA
Practice Address - Zip Code:02067-2841
Practice Address - Country:US
Practice Address - Phone:781-784-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA873252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency