Provider Demographics
NPI:1558846287
Name:ROUNDTREE, LISA RENEA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEA
Last Name:ROUNDTREE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 WILLIS RD
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:OK
Mailing Address - Zip Code:73449-5265
Mailing Address - Country:US
Mailing Address - Phone:903-271-8281
Mailing Address - Fax:
Practice Address - Street 1:3515 S PARK AVE
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-7342
Practice Address - Country:US
Practice Address - Phone:903-327-8537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209322224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant