Basic Information
| Provider Information | |||||||||
| NPI: | 1073727541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIROIS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTAL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLOOM | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | RENE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | COTAL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 37 ELLIS DR | ||||||||
| Address2: | |||||||||
| City: | DENNIS PORT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026391507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083945089 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 63 DANBURY ROAD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002780332 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1016 | MA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | A415 | AR | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 1232 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 0213 | NH | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 07884 | FL | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.