Provider Demographics
NPI:1164856225
Name:SIMON, MATTHEW LEONARD (COTA/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEONARD
Last Name:SIMON
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 1:2134 E DALEY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-7508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17490 N 93RD ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6323
Practice Address - Country:US
Practice Address - Phone:480-630-3749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1683224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification