Provider Demographics
NPI:1073917167
Name:CARRASCO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CARRASCO
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 1:18491 N JAMESTOWN
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-4290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 E 71ST ST
Practice Address - Street 2:SUITE 7120
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6542
Practice Address - Country:US
Practice Address - Phone:918-367-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK865224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant