Provider Demographics
NPI:1851663207
Name:PAVAO, AMANDA A (DS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:PAVAO
Suffix:
Gender:F
Credentials:DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02715-1128
Mailing Address - Country:US
Mailing Address - Phone:508-675-5778
Mailing Address - Fax:
Practice Address - Street 1:636 ROCK ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3438
Practice Address - Country:US
Practice Address - Phone:508-675-5778
Practice Address - Fax:508-675-9889
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator