Provider Demographics
NPI:1033542196
Name:PENTECOST, WILLIAM DAVID (COTA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DAVID
Last Name:PENTECOST
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 1:1486 W COLVILLE CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4869
Mailing Address - Country:US
Mailing Address - Phone:208-954-3691
Mailing Address - Fax:
Practice Address - Street 1:331 E PARK ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2053
Practice Address - Country:US
Practice Address - Phone:208-549-0206
Practice Address - Fax:208-549-0536
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-168224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant