Provider Demographics
NPI:1700439114
Name:THERRIEN, COREY RICHARD (COTA/L)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:RICHARD
Last Name:THERRIEN
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 1:161 W RODEO RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6498
Mailing Address - Country:US
Mailing Address - Phone:520-421-4964
Mailing Address - Fax:520-421-4966
Practice Address - Street 1:161 W RODEO RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6498
Practice Address - Country:US
Practice Address - Phone:520-421-4964
Practice Address - Fax:520-421-4966
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-007108224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty