Provider Demographics
NPI:1104261635
Name:WAUTHIER, CONSTANCE KUMIKO (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:KUMIKO
Last Name:WAUTHIER
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PAUL ST APT 22
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2472
Mailing Address - Country:US
Mailing Address - Phone:217-369-3873
Mailing Address - Fax:
Practice Address - Street 1:340 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2700
Practice Address - Country:US
Practice Address - Phone:781-619-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10692225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist