Provider Demographics
NPI:1073071080
Name:RA, GREGORY (COTA/L)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RA
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 1:2112 WINDSOR PARK CT
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4977
Mailing Address - Country:US
Mailing Address - Phone:646-552-3028
Mailing Address - Fax:
Practice Address - Street 1:150 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2298
Practice Address - Country:US
Practice Address - Phone:646-505-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009953224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant