Provider Demographics
NPI:1316548001
Name:MINERICH, LISA FERGUSON (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:FERGUSON
Last Name:MINERICH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FERN LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN SHORES
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3719
Mailing Address - Country:US
Mailing Address - Phone:301-785-0556
Mailing Address - Fax:
Practice Address - Street 1:4800 S CROATAN HWY
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9704
Practice Address - Country:US
Practice Address - Phone:252-449-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7631225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Single Specialty