Provider Demographics
NPI:1205017795
Name:EDMONDS, LISA A (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:EDMONDS
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 1:4411 MONTANO RD NW
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3235
Mailing Address - Country:US
Mailing Address - Phone:505-898-8300
Mailing Address - Fax:505-898-8313
Practice Address - Street 1:4411 MONTANO RD NW
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3235
Practice Address - Country:US
Practice Address - Phone:505-898-8300
Practice Address - Fax:505-898-8313
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist