Basic Information
| Provider Information | |||||||||
| NPI: | 1689741050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETULLIO | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S HENDERSON RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107685940 | ||||||||
| FaxNumber: | 6107685947 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S HENDERSON RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107685940 | ||||||||
| FaxNumber: | 6107685947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | OC008942 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | OC008942 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1495761 | 01 | PA | IBC - PERSONAL CHOICE | OTHER | 2184913000 | 01 | PA | IBC - KEYSTONE | OTHER |