Provider Demographics
NPI:1114509742
Name:KOVACICH, MICHAEL REGIS (COTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:REGIS
Last Name:KOVACICH
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 1:745 GREENVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:PA
Mailing Address - Zip Code:16137-5070
Mailing Address - Country:US
Mailing Address - Phone:724-662-5400
Mailing Address - Fax:
Practice Address - Street 1:745 GREENVILLE RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-5070
Practice Address - Country:US
Practice Address - Phone:724-662-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAL002214224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant