Provider Demographics
NPI:1619459252
Name:CHAVARRIA, IVAN (COTA)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:CHAVARRIA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 DURRILL RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-3649
Mailing Address - Country:US
Mailing Address - Phone:915-255-6354
Mailing Address - Fax:
Practice Address - Street 1:10064 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:TX
Practice Address - Zip Code:79927-1801
Practice Address - Country:US
Practice Address - Phone:915-773-0744
Practice Address - Fax:915-790-0612
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214956224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant