Provider Demographics
NPI:1972099158
Name:RYAN, JOSEPHINE MARY (COTA/L)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:MARY
Last Name:RYAN
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 1:4159 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-8302
Mailing Address - Country:US
Mailing Address - Phone:907-299-0332
Mailing Address - Fax:
Practice Address - Street 1:1230 OCEAN DR STE 2
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7911
Practice Address - Country:US
Practice Address - Phone:907-756-3715
Practice Address - Fax:800-221-8541
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK120412224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK120412OtherALASKA STATE PHYSICAL AND OCCUPATIONAL THERAPY COTA LISENCE