Basic Information
| Provider Information | |||||||||
| NPI: | 1790894012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | OTR/L, CHT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | OTR/L, CHT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 8540 QUADAY AVE NE | ||||||||
| Address2: | |||||||||
| City: | OTSEGO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553306522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634410298 | ||||||||
| FaxNumber: | 7634410591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 102714 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
No ID Information.