Provider Demographics
NPI:1093104812
Name:COOLEY, LISA D (OTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:COOLEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20104 NY STATE RTE 3
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5560
Mailing Address - Country:US
Mailing Address - Phone:315-779-7100
Mailing Address - Fax:131-577-9710
Practice Address - Street 1:20104 NY STATE RTE 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5560
Practice Address - Country:US
Practice Address - Phone:315-779-7100
Practice Address - Fax:131-577-9710
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007917-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist