Provider Demographics
NPI:1417933821
Name:GREAK, LISA MARIE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:GREAK
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 1:321 GARLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-6238
Mailing Address - Country:US
Mailing Address - Phone:979-297-3365
Mailing Address - Fax:979-297-3541
Practice Address - Street 1:321 GARLAND DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6238
Practice Address - Country:US
Practice Address - Phone:979-297-3365
Practice Address - Fax:979-297-3541
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F2778Medicare PIN