Provider Demographics
NPI:1609873777
Name:FOWLER, LISA M (OTRL, CHT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:OTRL, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4172 W PYRACANTHA CIR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-1339
Mailing Address - Country:US
Mailing Address - Phone:520-400-0726
Mailing Address - Fax:520-293-5454
Practice Address - Street 1:437 W THURBER RD
Practice Address - Street 2:STE 2
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-6822
Practice Address - Country:US
Practice Address - Phone:520-293-5252
Practice Address - Fax:520-293-5454
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1867225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86059251885704C007OtherTRICARE NUMBER
AZ6013520001OtherMEDICARE PTAN DME
AZ108730Medicare PIN
AZ86059251885704C007OtherTRICARE NUMBER