Provider Demographics
NPI:1598375958
Name:FORTIN, TAYLOR ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANN
Last Name:FORTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NH
Mailing Address - Zip Code:03593-5259
Mailing Address - Country:US
Mailing Address - Phone:603-915-3495
Mailing Address - Fax:
Practice Address - Street 1:91 COUNTRY VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3142
Practice Address - Country:US
Practice Address - Phone:603-788-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist