Provider Demographics
NPI:1477689594
Name:GOLD, LISA (MS, OTR L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:MS, OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 N WOOD ST
Mailing Address - Street 2:102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3265
Mailing Address - Country:US
Mailing Address - Phone:773-276-7876
Mailing Address - Fax:773-276-4412
Practice Address - Street 1:1259 N WOOD ST
Practice Address - Street 2:102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3265
Practice Address - Country:US
Practice Address - Phone:773-276-7876
Practice Address - Fax:773-276-4412
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist