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General NPI Number Information
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NPI Number | 1679167720
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Entity Type | Organization
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Legal Business Name | OTA THE KOOMAR CENTER, LLC
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Dates
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Enumeration Date | 03/01/2021
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Last Update Date | 03/01/2021
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Provider Practice Location Address
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Address Line | 74 BRIDGE ST
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City | NEWTON
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State | MA
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Zip | 02458-1147
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Country | US
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Telephone | 617-969-4410
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Fax |
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Provider Business Mailing Address
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Address Line | 15245 SHADY GROVE RD STE 110
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City | ROCKVILLE
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State | MD
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Zip | 20850-7202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TAYLOR DAVIDSON
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Credential |
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Telephone | 617-999-9585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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