Provider Demographics
NPI:1912340555
Name:PAK, SIVANTHAN (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:SIVANTHAN
Middle Name:
Last Name:PAK
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-2903
Practice Address - Country:US
Practice Address - Phone:360-123-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2014-01-09
Deactivation Date:2013-07-16
Deactivation Code:
Reactivation Date:2014-01-09
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program