Provider Demographics
NPI:1912101627
Name:RICHARDSON, LISA HERLOCKER (COTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:HERLOCKER
Last Name:RICHARDSON
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 1:35296 PICKLER RD
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-9659
Mailing Address - Country:US
Mailing Address - Phone:198-058-1076
Mailing Address - Fax:
Practice Address - Street 1:33426 OLD SALISBURY ROAD
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28002
Practice Address - Country:US
Practice Address - Phone:704-986-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4431224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC225X00000XMedicare ID - Type UnspecifiedCOTA