=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942546684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ALVIN PAVEY COTA/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2012
-----------------------------------------------------
Last Update Date | 12/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 ADAMS ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-251-4303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1022 ADAMS ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-251-4303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 304651
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------