Healthcare Provider Details

I. General information

NPI: 1063538361
Provider Name (Legal Business Name): KENNETH D PAVAO OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 HATHAWAY RD
NEW BEDFORD MA
02740-1916
US

IV. Provider business mailing address

17 ADIRONDACK LN
WESTPORT MA
02790-3311
US

V. Phone/Fax

Practice location:
  • Phone: 508-996-6763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3001
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number00376
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: