Provider Demographics
NPI:1073970851
Name:SMALLWOOD, LISA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WEHOFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 MADRONA ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-8318
Practice Address - Country:US
Practice Address - Phone:719-659-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-LIC-3996225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist