Provider Demographics
NPI:1699237958
Name:RIOS, LISA MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:RIOS
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 1:5320 BENJAMIN CT
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9469
Mailing Address - Country:US
Mailing Address - Phone:916-995-3774
Mailing Address - Fax:
Practice Address - Street 1:2030 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3785
Practice Address - Country:US
Practice Address - Phone:209-577-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4771224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant