Basic Information
| Provider Information | |||||||||
| NPI: | 1093383218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMBLE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530834246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209175250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19395 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629237101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6170-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.