Healthcare Provider Details

I. General information

NPI: 1003653148
Provider Name (Legal Business Name): KYLE ESCOVEDO OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 BRIGHTON AVE STE 201
PORTLAND ME
04102-2365
US

IV. Provider business mailing address

3478 KENNETH DR
PALO ALTO CA
94303-4218
US

V. Phone/Fax

Practice location:
  • Phone: 207-775-4000
  • Fax:
Mailing address:
  • Phone: 650-465-4381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4342
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: