Provider Demographics
NPI:1386018182
Name:HAIRSTON, LAMONICA LYNIECE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:LAMONICA
Middle Name:LYNIECE
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:LAMONICA
Other - Middle Name:LYNIECE
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14306 DANTE AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-1326
Mailing Address - Country:US
Mailing Address - Phone:708-248-4456
Mailing Address - Fax:
Practice Address - Street 1:14306 DANTE AVE
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-1326
Practice Address - Country:US
Practice Address - Phone:708-248-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004306224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant