Provider Demographics
NPI:1740782481
Name:CLOSE, KEELY JOANNA (COTA/L)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:JOANNA
Last Name:CLOSE
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 1:6717 N 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1004
Mailing Address - Country:US
Mailing Address - Phone:602-718-6883
Mailing Address - Fax:
Practice Address - Street 1:7550 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4618
Practice Address - Country:US
Practice Address - Phone:602-906-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6400224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant