Provider Demographics
NPI:1023159779
Name:MATA, GEORGE JAMES JR (COTA/L)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:JAMES
Last Name:MATA
Suffix:JR
Gender:M
Credentials:COTA/L
Other - Prefix:MR
Other - First Name:GEORGE
Other - Middle Name:JAMES
Other - Last Name:SALAMUNEC
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:222 W CLARENDON AVE APT 207
Mailing Address - Street 2:APT #207
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3487
Mailing Address - Country:US
Mailing Address - Phone:602-516-0162
Mailing Address - Fax:
Practice Address - Street 1:10251 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1305
Practice Address - Country:US
Practice Address - Phone:602-995-0867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1917224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant