Provider Demographics
NPI:1811622905
Name:DUTTON, MEMORY ALANA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MEMORY
Middle Name:ALANA
Last Name:DUTTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MEMORY
Other - Middle Name:ALANA
Other - Last Name:SHETTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3623 ZUNI
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-2237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3623 ZUNI
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-2237
Practice Address - Country:US
Practice Address - Phone:770-597-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120150225X00000X
AZOTH-008607225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist