Provider Demographics
NPI:1275660714
Name:MCINTOSH, LISA (OTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:OTA
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 1838
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-1838
Mailing Address - Country:US
Mailing Address - Phone:863-687-0931
Mailing Address - Fax:863-687-4021
Practice Address - Street 1:2000 E EDGEWOOD DR
Practice Address - Street 2:SUITE 114
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3653
Practice Address - Country:US
Practice Address - Phone:863-577-1981
Practice Address - Fax:863-687-1983
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA8317224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant