Provider Demographics
NPI:1720514136
Name:COULBOURN, MCKENNA WILKIE (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:MCKENNA
Middle Name:WILKIE
Last Name:COULBOURN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
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Mailing Address - Street 1:117 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WENHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01984-1926
Mailing Address - Country:US
Mailing Address - Phone:978-430-8929
Mailing Address - Fax:
Practice Address - Street 1:28 FOREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:ROWLEY
Practice Address - State:MA
Practice Address - Zip Code:01969-2150
Practice Address - Country:US
Practice Address - Phone:978-430-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12315225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics