Provider Demographics
NPI:1821478843
Name:ANDERSON, AUSTIN (COTA/L)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
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 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-783-2482
Mailing Address - Fax:
Practice Address - Street 1:308 W EMMA ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1940
Practice Address - Country:US
Practice Address - Phone:509-248-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60558654224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant