Healthcare Provider Details

I. General information

NPI: 1134916018
Provider Name (Legal Business Name): GREGORY ALAN HARRIS OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 WYOMING BLVE NE STE. 108
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

5345 WYOMING BLVE NE STE. 108
ALBUQERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-537-9906
  • Fax: 505-317-2532
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2025-0056
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: