Provider Demographics
NPI:1114469996
Name:LARREA, MICHAEL CHAFIC (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAFIC
Last Name:LARREA
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 1:7003 W 34TH ST N
Mailing Address - Street 2:APT # 908
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-2562
Mailing Address - Country:US
Mailing Address - Phone:316-941-7898
Mailing Address - Fax:
Practice Address - Street 1:650 LAKE RD
Practice Address - Street 2:
Practice Address - City:ATWOOD
Practice Address - State:KS
Practice Address - Zip Code:67730-1535
Practice Address - Country:US
Practice Address - Phone:785-626-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01190224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant