Provider Demographics
NPI:1548326267
Name:MAXSON, DIANE LAROSE (OTR)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LAROSE
Last Name:MAXSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:RENEE
Other - Last Name:LAROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:14 LAWRENCE CIR
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2825
Mailing Address - Country:US
Mailing Address - Phone:508-359-9893
Mailing Address - Fax:781-821-9950
Practice Address - Street 1:500 CHAPMAN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2093
Practice Address - Country:US
Practice Address - Phone:781-821-9955
Practice Address - Fax:781-821-9950
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH 237 OT225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOT0092OtherBLUE CROSS BLUE SHIELD MA