Provider Demographics
NPI:1326273749
Name:JELLISON, LISA L (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:JELLISON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683-2116
Mailing Address - Country:US
Mailing Address - Phone:724-887-5652
Mailing Address - Fax:
Practice Address - Street 1:75 HICKLE ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4350
Practice Address - Country:US
Practice Address - Phone:724-437-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010897225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist