Provider Demographics
NPI:1881829414
Name:RANDOL, LISA MARIE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:RANDOL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:ROBISON-PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:2039 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4136
Mailing Address - Country:US
Mailing Address - Phone:616-307-3497
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:888-873-4221
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4365224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant