Provider Demographics
NPI:1235332214
Name:WILD, LISA B (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:WILD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:B
Other - Last Name:GLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:9494 E BECKER LANE
Mailing Address - Street 2:LIFE CARE CENTER OF SCOTTSDALE
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-760-4236
Mailing Address - Fax:
Practice Address - Street 1:9494 E BECKER LANE
Practice Address - Street 2:LIFE CARE CENTER OF SCOTTSDALE
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-760-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3619225X00000X
MI5201006730225X00000X
FL3633225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist