Provider Demographics
NPI:1477170512
Name:VISTARAKULA, LAUREN (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:VISTARAKULA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:PITTARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4335 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3404
Mailing Address - Country:US
Mailing Address - Phone:540-315-3210
Mailing Address - Fax:540-566-5149
Practice Address - Street 1:4335 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3404
Practice Address - Country:US
Practice Address - Phone:540-315-3210
Practice Address - Fax:540-566-5149
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-05
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist