Provider Demographics
NPI:1093383853
Name:YOO, SAM WON (COTA/L)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:WON
Last Name:YOO
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:PO BOX 50218
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-0218
Mailing Address - Country:US
Mailing Address - Phone:480-398-4280
Mailing Address - Fax:844-526-2649
Practice Address - Street 1:854 E WILLIAMS FIELD RD STE 105
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-0703
Practice Address - Country:US
Practice Address - Phone:480-398-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ500165Medicaid