Provider Demographics
NPI:1447793146
Name:PAVKOV, LOIS JEAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:JEAN
Last Name:PAVKOV
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WOODCROSS DR APT 1202
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2365
Mailing Address - Country:US
Mailing Address - Phone:803-719-2206
Mailing Address - Fax:
Practice Address - Street 1:100 JOSEPH WALKER DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6971
Practice Address - Country:US
Practice Address - Phone:803-936-0310
Practice Address - Fax:803-926-9599
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2310174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist