Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 5731 | MA |
NPI | 1033259247 |
---|---|
Provider Name | Kristen Manfredi |
First Address | Walpole, MA 02081-1020 |
Second Address | Weymouth, MA 02189-3137 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
OT0189 | BCBS PROVIDER ID (01) | MA |