Provider Demographics
NPI:1982370722
Name:PATIL, PRAFULLA
Entity Type:Individual
Prefix:
First Name:PRAFULLA
Middle Name:
Last Name:PATIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 KATHERINE RD
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2749
Mailing Address - Country:US
Mailing Address - Phone:857-352-7636
Mailing Address - Fax:
Practice Address - Street 1:55 KATHERINE RD
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2749
Practice Address - Country:US
Practice Address - Phone:857-352-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10768225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10768OtherMA OT LICENSE NUMBER