Provider Demographics
NPI:1497865513
Name:MARTIN, LISA MARIE (OT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MARTIN
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 1:4444 FOREST PARK AVE
Mailing Address - Street 2:C B 8505
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2212
Mailing Address - Country:US
Mailing Address - Phone:314-286-1600
Mailing Address - Fax:314-286-1601
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1096
Practice Address - Fax:314-286-1601
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004002630225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist