Provider Demographics
NPI:1952618167
Name:COLLINS, LAURIE JO (COTA/L)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JO
Last Name:COLLINS
Suffix:
Gender:F
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 1:229 COLLINS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:WEST GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-3414
Mailing Address - Country:US
Mailing Address - Phone:207-441-2677
Mailing Address - Fax:
Practice Address - Street 1:1116 WEBBER POND RD
Practice Address - Street 2:
Practice Address - City:VASSALBORO
Practice Address - State:ME
Practice Address - Zip Code:04989-3949
Practice Address - Country:US
Practice Address - Phone:079-233-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA1117224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME611592446Medicaid