Provider Demographics
NPI:1346513157
Name:PAAK, LISSA ELLEN (OT)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:ELLEN
Last Name:PAAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 W AZTEC BLVD
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1805
Mailing Address - Country:US
Mailing Address - Phone:505-334-3695
Mailing Address - Fax:
Practice Address - Street 1:1607 W AZTEC BLVD
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1805
Practice Address - Country:US
Practice Address - Phone:505-334-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM895225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist