Provider Demographics
NPI:1174931984
Name:CHOWANEC, RICHARD (OTA/L)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CHOWANEC
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 GOLF PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-4252
Mailing Address - Country:US
Mailing Address - Phone:570-698-5647
Mailing Address - Fax:570-698-7742
Practice Address - Street 1:1404 GOLF PARK DR
Practice Address - Street 2:
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-4252
Practice Address - Country:US
Practice Address - Phone:570-698-5647
Practice Address - Fax:570-698-7742
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP-000987L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102602636-0001Medicaid
PA10182OtherFACILITY LICENSE NUMBER
PA1831498567OtherNPI
PA10182OtherFACILITY LICENSE NUMBER