1356576862 NPI number — MRS. MARY AGNES PAVAO COTA/L

Table of content: MRS. MARY AGNES PAVAO COTA/L (NPI 1356576862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356576862 NPI number — MRS. MARY AGNES PAVAO COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVAO
Provider First Name:
MARY
Provider Middle Name:
AGNES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356576862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
894 HENRICO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23608-9320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-329-7420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1904 GLEN LAKES CIR. N.
Provider Second Line Business Practice Location Address:
THERAPY PLAYHOUSE
Provider Business Practice Location Address City Name:
ST. PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-423-0060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OTA 10884 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)