Healthcare Provider Details

I. General information

NPI: 1962005553
Provider Name (Legal Business Name): KEVIN BRADY ACCINELLI COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 6TH AVE SW
ALBANY OR
97321-1917
US

IV. Provider business mailing address

635 34TH AVE SE APT 4
ALBANY OR
97322-3803
US

V. Phone/Fax

Practice location:
  • Phone: 541-926-8664
  • Fax:
Mailing address:
  • Phone: 541-404-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number443811
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: