Provider Demographics
NPI:1457736803
Name:TIMRICK, LISA (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TIMRICK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 SQUIRES DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1050
Mailing Address - Country:US
Mailing Address - Phone:708-638-8603
Mailing Address - Fax:
Practice Address - Street 1:760 NORTH DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-9216
Practice Address - Country:US
Practice Address - Phone:321-254-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13707224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13707Medicaid