Provider Demographics
NPI:1679697502
Name:PEZZULLO, ROBERT A (COTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:PEZZULLO
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 1:161 W SHORE RD APT A9
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-1152
Mailing Address - Country:US
Mailing Address - Phone:401-732-6768
Mailing Address - Fax:
Practice Address - Street 1:161 W SHORE RD APT A9
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-1152
Practice Address - Country:US
Practice Address - Phone:401-732-6768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00383224Z00000X
MA03018224Z00000X
CT001008224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant