Provider Demographics
NPI:1245441930
Name:VAN, KIRT CARL (COTA)
Entity type:Individual
Prefix:
First Name:KIRT
Middle Name:CARL
Last Name:VAN
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 1:140 RAPHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1309
Mailing Address - Country:US
Mailing Address - Phone:508-269-5971
Mailing Address - Fax:
Practice Address - Street 1:1 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1503
Practice Address - Country:US
Practice Address - Phone:401-438-3250
Practice Address - Fax:401-438-4813
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00055224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant