Provider Demographics
NPI:1467550137
Name:MCKEOWN, LISA S (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:MCKEOWN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1955225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOT0023OtherBLUE CROSS
MAB501027OtherCIGNA
MA0020071OtherNEIGHBORHOOD HEALTH PLAN
MA0311138Medicaid
MAOT0023OtherBLUE CROSS