Provider Demographics
NPI:1033194980
Name:WREN, LISA G (OT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:G
Last Name:WREN
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 1:1255 HIGHWAY 332
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-9320
Mailing Address - Country:US
Mailing Address - Phone:870-777-6798
Mailing Address - Fax:870-887-6880
Practice Address - Street 1:12018 HIGHWAY 196
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1280
Practice Address - Country:US
Practice Address - Phone:870-653-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1502225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141437721Medicaid
AROTR1502OtherSTATE LICENSE NUMBER
AR141437721Medicaid