Provider Demographics
NPI:1861975823
Name:ZIMMERMAN, ILISSA GENEEN (COTA/L)
Entity type:Individual
Prefix:
First Name:ILISSA
Middle Name:GENEEN
Last Name:ZIMMERMAN
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 1:595 E EL PASO AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2808
Mailing Address - Country:US
Mailing Address - Phone:561-951-3472
Mailing Address - Fax:
Practice Address - Street 1:595 E EL PASO AVE APT 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2808
Practice Address - Country:US
Practice Address - Phone:561-951-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3992224Z00000X
FL15853224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant