Provider Demographics
NPI:1538812680
Name:ARCHER, LADAWN (OTA)
Entity type:Individual
Prefix:
First Name:LADAWN
Middle Name:
Last Name:ARCHER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 S CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3412
Mailing Address - Country:US
Mailing Address - Phone:918-639-9133
Mailing Address - Fax:
Practice Address - Street 1:17287 W 32ND ST S
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-4774
Practice Address - Country:US
Practice Address - Phone:918-639-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1279224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant