Basic Information
| Provider Information | |||||||||
| NPI: | 1376747907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVESQUE | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 42 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018903152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817212221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 243 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175237900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 8974 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8974 | 01 | MA | OT LICENSE | OTHER | 1074190 | 01 | US OT REGISTRATION | OTHER |