Provider Demographics
NPI:1992959662
Name:GOTELL, KERRIE
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:GOTELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 DIMMOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1945
Mailing Address - Country:US
Mailing Address - Phone:781-270-0222
Mailing Address - Fax:
Practice Address - Street 1:3 BURLINGTON WOODS
Practice Address - Street 2:SUITE 304
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4514
Practice Address - Country:US
Practice Address - Phone:781-270-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8170OtherLICENSE