Provider Demographics
NPI:1811663156
Name:KENT, DEREK JERRED (COTA/L)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JERRED
Last Name:KENT
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 1:600 CHARLES DR APT 232
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1193
Mailing Address - Country:US
Mailing Address - Phone:916-729-9600
Mailing Address - Fax:
Practice Address - Street 1:3305 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2990
Practice Address - Country:US
Practice Address - Phone:520-515-2754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-046990224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant