Provider Demographics
NPI:1093415333
Name:RAY, TREVOR RYAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:RYAN
Last Name:RAY
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 1:105 HOLMES PL
Mailing Address - Street 2:
Mailing Address - City:CYPRESS GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2313
Mailing Address - Country:US
Mailing Address - Phone:863-662-2179
Mailing Address - Fax:
Practice Address - Street 1:400 NORTH LAKE HOWARD DRIVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-875-3599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19228224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant