Provider Demographics
NPI:1780088245
Name:TRUDEAU, LISA ANN (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:TRUDEAU
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:PICARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:43 BROADLEAF LN
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5501
Mailing Address - Country:US
Mailing Address - Phone:860-995-7889
Mailing Address - Fax:
Practice Address - Street 1:43 BROADLEAF LN
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5501
Practice Address - Country:US
Practice Address - Phone:860-995-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000321174V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174V00000XOther Service ProvidersClinical Ethicist