Provider Demographics
NPI:1376801050
Name:SIRKO, LISA A (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:SIRKO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ANGRIST-SIRKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:7451 W POTTER DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9673
Mailing Address - Country:US
Mailing Address - Phone:623-640-5675
Mailing Address - Fax:
Practice Address - Street 1:5314 N. 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014
Practice Address - Country:US
Practice Address - Phone:602-277-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5064224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant