Provider Demographics
NPI:1962005553
Name:ACCINELLI, KEVIN BRADY (COTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRADY
Last Name:ACCINELLI
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 1:635 34TH AVE SE APT 4
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-3803
Mailing Address - Country:US
Mailing Address - Phone:541-404-3620
Mailing Address - Fax:
Practice Address - Street 1:1023 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1917
Practice Address - Country:US
Practice Address - Phone:541-926-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR443811224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant