Provider Demographics
NPI:1336853399
Name:STEVENS, TANNER SCOTT (COTA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:SCOTT
Last Name:STEVENS
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 1:800 NW 118TH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5970
Mailing Address - Country:US
Mailing Address - Phone:541-588-0219
Mailing Address - Fax:
Practice Address - Street 1:14420 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2504
Practice Address - Country:US
Practice Address - Phone:503-610-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR477927224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant