Provider Demographics
NPI:1124145073
Name:AUSTRIACO, KENNETH S (OT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:S
Last Name:AUSTRIACO
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E WASHINGTON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6438
Mailing Address - Country:US
Mailing Address - Phone:909-825-6716
Mailing Address - Fax:909-825-4339
Practice Address - Street 1:301 S FAIR OAKS AVE STE 401
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2562
Practice Address - Country:US
Practice Address - Phone:626-744-0411
Practice Address - Fax:626-744-0431
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT7381225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOT7381AMedicare ID - Type UnspecifiedPPIN