Provider Demographics
NPI:1063960425
Name:SHANEKA A LAVENDER, COTA/L
Entity type:Organization
Organization Name:SHANEKA A LAVENDER, COTA/L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA/L
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANEKA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-458-0699
Mailing Address - Street 1:55 S 133RD ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-6014
Mailing Address - Country:US
Mailing Address - Phone:678-458-0699
Mailing Address - Fax:
Practice Address - Street 1:55 S 133RD ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6014
Practice Address - Country:US
Practice Address - Phone:678-458-0699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5558224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty