Provider Demographics
NPI:1407058886
Name:NIEMANN, LARA LYNETTE (OTR, ATP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:LYNETTE
Last Name:NIEMANN
Suffix:
Gender:F
Credentials:OTR, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4534
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-4534
Mailing Address - Country:US
Mailing Address - Phone:432-638-8797
Mailing Address - Fax:432-687-4290
Practice Address - Street 1:1020 ANDREWS HWY STE E
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3811
Practice Address - Country:US
Practice Address - Phone:432-570-5079
Practice Address - Fax:432-687-4290
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109138225X00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1407058886Medicaid