Provider Demographics
NPI:1972881266
Name:MEDOW, IVY JOAN (COTA/L, CRC)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:JOAN
Last Name:MEDOW
Suffix:
Gender:F
Credentials:COTA/L, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1723
Mailing Address - Country:US
Mailing Address - Phone:480-229-6244
Mailing Address - Fax:
Practice Address - Street 1:17100 E. SHEA BLVD.
Practice Address - Street 2:STARS
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1847224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant