MEDICARE: TAYLOR DREW HICKS COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	046789	AZ

General Provider Information

NPI Number	:	1396345849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR DREW HICKS COTA/L

Provider Business Mailing Address
First Line	:	2913 E SUNLAND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3759
Country	:	US
Telephone Number	:	949-326-3368
Fax Number	:

Provider Business Practice Location Address
First Line	:	2913 E SUNLAND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3759
Country	:	US
Telephone Number	:	949-326-3368
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/26/2020

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