Provider Demographics
NPI:1376271569
Name:WILSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:10341 SHADOW VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-0181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14673 MIDWAY RD STE 1-111
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3171
Practice Address - Country:US
Practice Address - Phone:972-851-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217536224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4696826774Medicaid