Provider Demographics
NPI:1790918902
Name:SMITH, LISA JANELL (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANELL
Last Name:SMITH
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 1:2221 W DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3628
Mailing Address - Country:US
Mailing Address - Phone:918-615-6492
Mailing Address - Fax:918-615-6493
Practice Address - Street 1:2221 W DETROIT ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3628
Practice Address - Country:US
Practice Address - Phone:918-615-6492
Practice Address - Fax:918-615-6493
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant