Provider Demographics
NPI:1326245770
Name:DUNEVANT, LISA HENNING (OTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HENNING
Last Name:DUNEVANT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12729 OVERLOOK MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-6739
Mailing Address - Country:US
Mailing Address - Phone:704-405-7769
Mailing Address - Fax:
Practice Address - Street 1:12729 OVERLOOK MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-6739
Practice Address - Country:US
Practice Address - Phone:704-405-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist