Provider Demographics
NPI:1720478738
Name:TAVARES, DIANE (COTA/L)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TAVARES
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 1:195 HEALY ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-1280
Mailing Address - Country:US
Mailing Address - Phone:774-526-0097
Mailing Address - Fax:
Practice Address - Street 1:195 HEALY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1280
Practice Address - Country:US
Practice Address - Phone:774-526-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3715224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant