Provider Demographics
NPI:1083432074
Name:GUILBAULT, ELIZA POPPY (COTA/L, BS)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:POPPY
Last Name:GUILBAULT
Suffix:
Gender:F
Credentials:COTA/L, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 DANA ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-3001
Mailing Address - Country:US
Mailing Address - Phone:978-504-1379
Mailing Address - Fax:
Practice Address - Street 1:12 DANA ST UNIT 1
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-3001
Practice Address - Country:US
Practice Address - Phone:978-504-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4739224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant