Provider Demographics
NPI:1740663566
Name:GREGORY, PAUL R (COTA/L)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:GREGORY
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84326-0236
Mailing Address - Country:US
Mailing Address - Phone:435-716-2898
Mailing Address - Fax:
Practice Address - Street 1:1300 N 500 E SUITE 120
Practice Address - Street 2:SUITE 120
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-716-2880
Practice Address - Fax:435-716-2811
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335073-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant