Provider Demographics
NPI:1720210743
Name:REGER, LYNETTE LOUISE (COTA/L)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:LOUISE
Last Name:REGER
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:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:STOCKTON SPRINGS
Mailing Address - State:ME
Mailing Address - Zip Code:04981-0196
Mailing Address - Country:US
Mailing Address - Phone:207-567-3604
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:188-887-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA2241224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant