Provider Demographics
NPI:1861638629
Name:EICKHOLT, LAURA ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:EICKHOLT
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 1:1856 TOWNE PARK DR
Mailing Address - Street 2:APT 2B
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-8330
Mailing Address - Country:US
Mailing Address - Phone:419-615-9736
Mailing Address - Fax:
Practice Address - Street 1:5790 DENLINGER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1838
Practice Address - Country:US
Practice Address - Phone:937-529-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03759224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant