Provider Demographics
NPI:1891940862
Name:BLACK, LYNDEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:LYNDEE
Middle Name:
Last Name:BLACK
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 1:6551 PARK OF COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-8218
Mailing Address - Country:US
Mailing Address - Phone:800-347-2264
Mailing Address - Fax:
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4610
Practice Address - Country:US
Practice Address - Phone:508-421-1183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1045224Z00000X
CAOTA 1747224Z00000X
OHOTA 03939224Z00000X
MO2005017458224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant