Provider Demographics
NPI:1164020095
Name:HARRISON, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HARRISON
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:PO BOX 353842
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-3842
Mailing Address - Country:US
Mailing Address - Phone:386-793-3159
Mailing Address - Fax:
Practice Address - Street 1:83 PEPPERDINE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7498
Practice Address - Country:US
Practice Address - Phone:386-793-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA046825224Z00000X
MSOTA3726224Z00000X
NMOTA4227224Z00000X
NJ46TA09186500224Z00000X
TX214087224Z00000X
AL4394224Z00000X
FLOTA15358224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant