Provider Demographics
NPI:1043429285
Name:SIDENER, SCOT MICHAEL (COTA L)
Entity Type:Individual
Prefix:MR
First Name:SCOT
Middle Name:MICHAEL
Last Name:SIDENER
Suffix:
Gender:M
Credentials:COTA L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E MCDOWELL RD # 107-475
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1549
Mailing Address - Country:US
Mailing Address - Phone:602-206-8577
Mailing Address - Fax:480-288-4864
Practice Address - Street 1:530 E MCDOWELL RD # 107-475
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1549
Practice Address - Country:US
Practice Address - Phone:602-206-8577
Practice Address - Fax:480-288-4864
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2640224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant