Provider Demographics
NPI:1891951026
Name:WITHERELL, LYNNETTE MARIE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:MARIE
Last Name:WITHERELL
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 1:1500 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-2284
Mailing Address - Country:US
Mailing Address - Phone:217-732-8616
Mailing Address - Fax:
Practice Address - Street 1:1500 7TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2284
Practice Address - Country:US
Practice Address - Phone:217-732-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001593172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker