Provider Demographics
NPI:1275973042
Name:HAVERLY, LISA RENEE (MA/OT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:HAVERLY
Suffix:
Gender:F
Credentials:MA/OT
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:BUSSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA/OT
Mailing Address - Street 1:477 PERCH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-549-6021
Mailing Address - Fax:
Practice Address - Street 1:477 PERCH LAKE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-549-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3124-26225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics