Provider Demographics
NPI:1609057181
Name:ANDERSON, LISA MARIE (MSOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA MARIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 JAQUITH RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:NH
Mailing Address - Zip Code:03450-5217
Mailing Address - Country:US
Mailing Address - Phone:603-827-2904
Mailing Address - Fax:
Practice Address - Street 1:12 JAQUITH RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:NH
Practice Address - Zip Code:03450-5217
Practice Address - Country:US
Practice Address - Phone:603-827-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30417339Medicaid
NH30417339Medicaid