Provider Demographics
NPI:1215001938
Name:ENTWISTLE, LISA ANN (OTR)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:ENTWISTLE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11097 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ANN
Mailing Address - State:MO
Mailing Address - Zip Code:63074-1509
Mailing Address - Country:US
Mailing Address - Phone:314-213-8100
Mailing Address - Fax:314-213-8610
Practice Address - Street 1:11097 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-1509
Practice Address - Country:US
Practice Address - Phone:314-213-8100
Practice Address - Fax:314-213-8610
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005129225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO476134507Medicaid