Provider Demographics
NPI:1437406360
Name:GRAYSON, KELLY ANNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:GRAYSON
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 1:534 E MARCO POLO RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-1033
Mailing Address - Country:US
Mailing Address - Phone:661-889-5290
Mailing Address - Fax:
Practice Address - Street 1:3802 N 91ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2368
Practice Address - Country:US
Practice Address - Phone:623-772-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4913224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant