Provider Demographics
NPI:1356576862
Name:PAVAO, MARY AGNES (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AGNES
Last Name:PAVAO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 HENRICO CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-9320
Mailing Address - Country:US
Mailing Address - Phone:757-329-7420
Mailing Address - Fax:
Practice Address - Street 1:1904 GLEN LAKES CIR. N.
Practice Address - Street 2:THERAPY PLAYHOUSE
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-423-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 10884224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant