Provider Demographics
NPI:1376135467
Name:RICHARDS, SHANANDA M (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHANANDA
Middle Name:M
Last Name:RICHARDS
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 1:211 W LEATHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-6632
Mailing Address - Country:US
Mailing Address - Phone:307-351-1125
Mailing Address - Fax:
Practice Address - Street 1:4929 S VAL VISTA DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-0664
Practice Address - Country:US
Practice Address - Phone:480-795-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ046701224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant