Provider Demographics
NPI:1699805473
Name:WAYCASTER, LELIA (OTR/L)
Entity type:Individual
Prefix:
First Name:LELIA
Middle Name:
Last Name:WAYCASTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 KNOB CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5343
Mailing Address - Country:US
Mailing Address - Phone:423-291-1411
Mailing Address - Fax:
Practice Address - Street 1:629 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2559
Practice Address - Country:US
Practice Address - Phone:423-722-2062
Practice Address - Fax:678-494-6908
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TN3826225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics