Basic Information
Provider Information
NPI: 1003152653
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WHITTET
FirstName: MACKENZIE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: COTA/L
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BRETON
OtherFirstName: MACKENZIE
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: COTA/L
OtherLastNameType: 1
Mailing Information
Address1: 500 CUMMINGS CTR
Address2: SUITE 3850
City: BEVERLY
State: MA
PostalCode: 019156142
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 500 CUMMINGS CTR
Address2: SUITE 3850
City: BEVERLY
State: MA
PostalCode: 019156142
CountryCode: US
TelephoneNumber: 9782320332
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/28/2012
LastUpdateDate: 03/18/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
224Z00000X3629MAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant 
224Z00000X293541MAN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant 

No ID Information.


Home