Provider Demographics
NPI:1033769625
Name:STOUGHTON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STOUGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-5002
Mailing Address - Country:US
Mailing Address - Phone:715-579-3052
Mailing Address - Fax:
Practice Address - Street 1:1270 GOLF VIEW DR
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-5002
Practice Address - Country:US
Practice Address - Phone:715-579-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012338225X00000X
CA20244225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist