Basic Information
| Provider Information | |||||||||
| NPI: | 1073639688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | LIESA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4501 HIGHWAY 39 N | ||||||||
| Address2: | APT 13B | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393011073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019373702 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 8005176935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | TA1993 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.