Provider Demographics
NPI:1497731186
Name:GERVAIS, LISE (OT)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:GERVAIS
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 1:155 GEORGE WASHINGTON BLVD
Mailing Address - Street 2:UNIT 410
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-3000
Mailing Address - Country:US
Mailing Address - Phone:508-923-6032
Mailing Address - Fax:508-923-6361
Practice Address - Street 1:109 RHODE ISLAND RD
Practice Address - Street 2:SHRIVER
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1370
Practice Address - Country:US
Practice Address - Phone:508-923-6032
Practice Address - Fax:508-923-6361
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69345Medicare ID - Type Unspecified