Provider Demographics
NPI:1801093380
Name:CADWALLADER, BRENT ALLEN (COTA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ALLEN
Last Name:CADWALLADER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MARY ST
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1147
Mailing Address - Country:US
Mailing Address - Phone:937-587-0176
Mailing Address - Fax:
Practice Address - Street 1:5900 MEADOW CREEK DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-5641
Practice Address - Country:US
Practice Address - Phone:513-248-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.01998224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616533Medicaid