Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 1381 | WV |
NPI | 1003932914 |
---|---|
Provider Name | Mrs. Candace Leigh Lusk |
First Address | Kopperston, WV 24854-0211 |
Second Address | Logan, WV 25601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2007 |
Last Update Date | 08/07/2007 |