Provider Demographics
NPI:1790117455
Name:KING, CHANA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:CHANA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E BARBARITA AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4566
Mailing Address - Country:US
Mailing Address - Phone:602-367-6495
Mailing Address - Fax:
Practice Address - Street 1:10049 E DYNAMITE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3694
Practice Address - Country:US
Practice Address - Phone:480-419-0848
Practice Address - Fax:480-538-5258
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5388224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant