Provider Demographics
NPI:1821514720
Name:LADUKE, LIESL (COTA)
Entity Type:Individual
Prefix:
First Name:LIESL
Middle Name:
Last Name:LADUKE
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 1:3800 N TANI RD APT B
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1129
Mailing Address - Country:US
Mailing Address - Phone:217-274-6721
Mailing Address - Fax:
Practice Address - Street 1:6550 E 2ND ST STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-3523
Practice Address - Country:US
Practice Address - Phone:928-771-9327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant