Provider Demographics
NPI:1194214965
Name:DERBAK, ANNA (COTA/L)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:DERBAK
Suffix:
Gender:F
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 1:4434 E CAROL ANN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4257
Mailing Address - Country:US
Mailing Address - Phone:602-334-6184
Mailing Address - Fax:
Practice Address - Street 1:16455 E AVENUE OF THE FOUNTAINS
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-8307
Practice Address - Country:US
Practice Address - Phone:480-816-5805
Practice Address - Fax:480-816-5807
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7412224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant