Provider Demographics
NPI:1992477228
Name:TREJO-DAVIS, IRMADRIANA S (COTA)
Entity type:Individual
Prefix:
First Name:IRMADRIANA
Middle Name:S
Last Name:TREJO-DAVIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 VON SCHEELE DR APT 522
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4352
Mailing Address - Country:US
Mailing Address - Phone:682-597-8965
Mailing Address - Fax:
Practice Address - Street 1:3100 SCHOFIELD RD BLDG 1179
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7577
Practice Address - Country:US
Practice Address - Phone:210-808-2269
Practice Address - Fax:210-916-6749
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215876224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant