Provider Demographics
NPI:1467836064
Name:OOTHOUDT, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:OOTHOUDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PEABODY ST
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-5407
Mailing Address - Country:US
Mailing Address - Phone:603-729-0056
Mailing Address - Fax:603-729-0069
Practice Address - Street 1:406 COURT ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3600
Practice Address - Country:US
Practice Address - Phone:603-524-0466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2551225X00000X
NH0519224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant