Provider Demographics
NPI:1417711508
Name:HALVORSON, CODY J (OTR/L)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:J
Last Name:HALVORSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 LADNER RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:ME
Mailing Address - Zip Code:04740-4316
Mailing Address - Country:US
Mailing Address - Phone:207-227-9957
Mailing Address - Fax:
Practice Address - Street 1:103 BOULDER POINT DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3168
Practice Address - Country:US
Practice Address - Phone:603-536-1881
Practice Address - Fax:603-238-2198
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT4562225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist