Provider Demographics
NPI:1518413400
Name:LIDDELL, HEATHER (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LIDDELL
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 1:6119 60TH CT SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-6472
Mailing Address - Country:US
Mailing Address - Phone:360-972-5123
Mailing Address - Fax:
Practice Address - Street 1:6119 60TH CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98513-6472
Practice Address - Country:US
Practice Address - Phone:360-972-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60562665224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant