Provider Demographics
NPI:1326356510
Name:CARACCIOLO, LISA ANN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:CARACCIOLO
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 1:48 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1602
Mailing Address - Country:US
Mailing Address - Phone:631-793-6767
Mailing Address - Fax:
Practice Address - Street 1:48 HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1602
Practice Address - Country:US
Practice Address - Phone:631-793-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006666-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant