Provider Demographics
NPI:1811355795
Name:AGYEKUM, ELISABETH RENEE (COTA/L)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:RENEE
Last Name:AGYEKUM
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 1:4012 105TH PL SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4661
Mailing Address - Country:US
Mailing Address - Phone:206-859-7827
Mailing Address - Fax:
Practice Address - Street 1:4012 105TH PL SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4661
Practice Address - Country:US
Practice Address - Phone:206-859-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60268951224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant