Provider Demographics
NPI:1629777180
Name:JASEK, WALTER LARRY (COTA/L)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LARRY
Last Name:JASEK
Suffix:
Gender:M
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 1:18633 OUTPOST RD
Mailing Address - Street 2:
Mailing Address - City:KEEDYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21756-1825
Mailing Address - Country:US
Mailing Address - Phone:443-220-4583
Mailing Address - Fax:
Practice Address - Street 1:2327 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5128
Practice Address - Country:US
Practice Address - Phone:443-220-4583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00816224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant