Provider Demographics
NPI:1114070125
Name:BRANTON, LISA LENORE (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LENORE
Last Name:BRANTON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8844 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5629
Mailing Address - Country:US
Mailing Address - Phone:850-969-1158
Mailing Address - Fax:
Practice Address - Street 1:3932 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2807
Practice Address - Country:US
Practice Address - Phone:850-434-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9825225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9281OtherBLUE CROSS BLUE SHIELD #