Provider Demographics
NPI:1255315966
Name:BARRY GOFBERG, LISA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BARRY GOFBERG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:550 SAINT CHARLES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3951
Mailing Address - Country:US
Mailing Address - Phone:805-449-1125
Mailing Address - Fax:805-449-4113
Practice Address - Street 1:550 SAINT CHARLES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3951
Practice Address - Country:US
Practice Address - Phone:805-449-1125
Practice Address - Fax:805-449-4113
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOT707AMedicare ID - Type UnspecifiedMEDICARE ID NUMBER