Provider Demographics
NPI:1306960950
Name:PROVENCHER, BRENDA LEE (OTR)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BUNKERHILL PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-2022
Mailing Address - Country:US
Mailing Address - Phone:508-835-4571
Mailing Address - Fax:
Practice Address - Street 1:120 SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2650
Practice Address - Country:US
Practice Address - Phone:617-663-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist