Healthcare Provider Details

I. General information

NPI: 1891452330
Provider Name (Legal Business Name): GREGORY RYAN SMITH MSOT, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 W ROSE GARDEN LN STE 4
PHOENIX AZ
85027-2725
US

IV. Provider business mailing address

18245 N PIMA RD APT 3091
SCOTTSDALE AZ
85255-6375
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-9912
  • Fax:
Mailing address:
  • Phone: 732-882-9774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR01031700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-008854
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: