Basic Information
| Provider Information | |||||||||
| NPI: | 1376801050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIRKO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | COTA | ||||||||
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| OtherLastName: | ANGRIST-SIRKO | ||||||||
| OtherFirstName: | LISA | ||||||||
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| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7451 W POTTER DR | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853089673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6236405675 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5314 N. 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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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 | 5064 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.