Provider Demographics
NPI:1194131003
Name:WHITEHEAD, MARIAN (COTA/L)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:WHITEHEAD
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 1:1718 NW ELM AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5118
Mailing Address - Country:US
Mailing Address - Phone:580-574-5680
Mailing Address - Fax:
Practice Address - Street 1:102 E GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3025
Practice Address - Country:US
Practice Address - Phone:580-353-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK748224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant