Provider Demographics
NPI:1427841808
Name:POLYDOOR, RAYMOND II (COTA/L)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:POLYDOOR
Suffix:II
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 1:2463 TRIBECA ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1143
Mailing Address - Country:US
Mailing Address - Phone:702-265-7531
Mailing Address - Fax:
Practice Address - Street 1:2560 MONTESSOURI ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3061
Practice Address - Country:US
Practice Address - Phone:702-686-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-3115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty