Provider Demographics
NPI:1326732066
Name:UTTERBACK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-7901
Mailing Address - Country:US
Mailing Address - Phone:281-476-0088
Mailing Address - Fax:
Practice Address - Street 1:4525 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-7901
Practice Address - Country:US
Practice Address - Phone:281-476-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1783-0523175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist