Provider Demographics
NPI:1861906646
Name:GERRITSEN, LISA CONNER (COTA/L)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:CONNER
Last Name:GERRITSEN
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 1:3932 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-8060
Mailing Address - Country:US
Mailing Address - Phone:540-598-8501
Mailing Address - Fax:
Practice Address - Street 1:5937 COVE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2403
Practice Address - Country:US
Practice Address - Phone:540-562-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000529224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant