Basic Information
| Provider Information | |||||||||
| NPI: | 1447776190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLACHE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | THUY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MOT/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRAN | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | THUY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MOT/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5285 | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688025285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086751853 | ||||||||
| FaxNumber: | 3082104121 | ||||||||
| Practice Location | |||||||||
| Address1: | 3004 W FAIDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688034109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086751853 | ||||||||
| FaxNumber: | 3082104121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 2144 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.