Provider Demographics
NPI:1407369119
Name:TEVIS, RYAN MATTHEW (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MATTHEW
Last Name:TEVIS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:MR
Other - First Name:RYAN
Other - Middle Name:MATTHEW
Other - Last Name:TEVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1103 184TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-7930
Mailing Address - Country:US
Mailing Address - Phone:253-222-3244
Mailing Address - Fax:
Practice Address - Street 1:630 S PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2111
Practice Address - Country:US
Practice Address - Phone:253-671-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60797198224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant