Provider Demographics
NPI:1568891117
Name:LIETZOW, DOREEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:LIETZOW
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 CARAWAY CIR NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-1318
Mailing Address - Country:US
Mailing Address - Phone:330-232-1350
Mailing Address - Fax:
Practice Address - Street 1:400 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8703
Practice Address - Country:US
Practice Address - Phone:330-868-4104
Practice Address - Fax:330-868-7714
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.05324224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant