Provider Demographics
NPI:1336777408
Name:BERESFORD, LANCE (COTA/L, DRS)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:BERESFORD
Suffix:
Gender:M
Credentials:COTA/L, DRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 PENN AVE STE 308
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2368
Practice Address - Country:US
Practice Address - Phone:515-263-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantDriving and Community Mobility