Provider Demographics
NPI:1629460241
Name:MENTIS, AUBREY CORLETTE JR (COTA)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:CORLETTE
Last Name:MENTIS
Suffix:JR
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 1:228 S FORESTVIEW CT
Mailing Address - Street 2:NONE
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-8225
Mailing Address - Country:US
Mailing Address - Phone:316-305-5073
Mailing Address - Fax:
Practice Address - Street 1:1601 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4409
Practice Address - Country:US
Practice Address - Phone:580-749-5923
Practice Address - Fax:580-749-5924
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1801136224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant