Provider Demographics
NPI:1316427578
Name:DICKEY, LISA ANN (COTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DICKEY
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:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:ZAVALLA
Mailing Address - State:TX
Mailing Address - Zip Code:75980-0833
Mailing Address - Country:US
Mailing Address - Phone:936-635-6365
Mailing Address - Fax:
Practice Address - Street 1:102 N BEECH ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-4718
Practice Address - Country:US
Practice Address - Phone:409-283-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213577224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213577OtherCOTA LICENSE