Provider Demographics
NPI:1003975384
Name:ROBERTSON, LISA G (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0726
Mailing Address - Country:US
Mailing Address - Phone:307-200-9520
Mailing Address - Fax:
Practice Address - Street 1:310 EAST BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-200-9520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist