Healthcare Provider Details

I. General information

NPI: 1467836064
Provider Name (Legal Business Name): DWAYNE OOTHOUDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 COURT ST
LACONIA NH
03246-3600
US

IV. Provider business mailing address

4 PEABODY ST
TILTON NH
03276-5407
US

V. Phone/Fax

Practice location:
  • Phone: 603-524-0466
  • Fax:
Mailing address:
  • Phone: 603-729-0056
  • Fax: 603-729-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0519
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2551
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: