Provider Demographics
NPI:1699014712
Name:HENDRICKSON, LISA RENEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:HENDRICKSON
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 1:107 WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608
Mailing Address - Country:US
Mailing Address - Phone:757-232-4366
Mailing Address - Fax:
Practice Address - Street 1:107 WOODBRIDGE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-8211
Practice Address - Country:US
Practice Address - Phone:757-232-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000873224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant