Provider Demographics
NPI:1093416851
Name:LAVELLE, TIMOTHY JARED (ORT/L)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JARED
Last Name:LAVELLE
Suffix:
Gender:M
Credentials:ORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 S MEADE ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:WEATHERLY
Practice Address - State:PA
Practice Address - Zip Code:18255-1599
Practice Address - Country:US
Practice Address - Phone:570-427-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC018757225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist