Provider Demographics
NPI:1558247866
Name:ANDERSON, TREY NICHOLAS (COTA/L)
Entity type:Individual
Prefix:MR
First Name:TREY
Middle Name:NICHOLAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 S QUANTUM WAY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8148
Mailing Address - Country:US
Mailing Address - Phone:775-385-0228
Mailing Address - Fax:
Practice Address - Street 1:5135 S QUANTUM WAY
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-8148
Practice Address - Country:US
Practice Address - Phone:775-385-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-050180224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant