Provider Demographics
NPI:1962117465
Name:TILLOTSONJAHELKA, LORI ANN (COTA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:TILLOTSONJAHELKA
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 1:6507 SANDY POINT CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5871
Mailing Address - Country:US
Mailing Address - Phone:310-863-7491
Mailing Address - Fax:
Practice Address - Street 1:6507 SANDY POINT CT
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-5871
Practice Address - Country:US
Practice Address - Phone:310-863-7491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5630224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty