Provider Demographics
NPI:1093049389
Name:SMITH, LISA ANN (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:GOUGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:7745 ASHER DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND PATENT
Mailing Address - State:NY
Mailing Address - Zip Code:13354-3601
Mailing Address - Country:US
Mailing Address - Phone:315-335-8187
Mailing Address - Fax:
Practice Address - Street 1:813 FAY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3009
Practice Address - Country:US
Practice Address - Phone:315-488-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015845225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist