Provider Demographics
NPI:1356757165
Name:WISE, LEE ANDREW (COTA)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANDREW
Last Name:WISE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3409
Mailing Address - Country:US
Mailing Address - Phone:434-426-4676
Mailing Address - Fax:
Practice Address - Street 1:301 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-3409
Practice Address - Country:US
Practice Address - Phone:434-426-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000439224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant