Provider Demographics
NPI:1790331718
Name:IBANEZ, JAVIER (COTA)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:IBANEZ
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 1:1414 SW 89TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6312
Mailing Address - Country:US
Mailing Address - Phone:405-703-8424
Mailing Address - Fax:
Practice Address - Street 1:1414 SW 89TH ST STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6312
Practice Address - Country:US
Practice Address - Phone:405-703-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2096224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant