Provider Demographics
NPI:1659769982
Name:LERCARA, JUSTINE MARY (COTA)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARY
Last Name:LERCARA
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 1:223A YORK STREET
Mailing Address - Street 2:
Mailing Address - City:POULTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05764
Mailing Address - Country:US
Mailing Address - Phone:845-321-9361
Mailing Address - Fax:
Practice Address - Street 1:9 HAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4832
Practice Address - Country:US
Practice Address - Phone:802-775-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0109090224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant