Provider Demographics
NPI:1346635547
Name:LISSON, ROBERT G (OT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:G
Last Name:LISSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7877 MACLEAN RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-9052
Mailing Address - Country:US
Mailing Address - Phone:850-459-7126
Mailing Address - Fax:850-597-7062
Practice Address - Street 1:1910 BUFORD BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4667
Practice Address - Country:US
Practice Address - Phone:850-459-7126
Practice Address - Fax:850-597-7062
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8395225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT8395OtherLICENSE