Provider Demographics
NPI:1639567936
Name:TILSON, LISA WALLNEY
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:WALLNEY
Last Name:TILSON
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 1:5301 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4940
Mailing Address - Country:US
Mailing Address - Phone:806-793-5947
Mailing Address - Fax:806-793-4544
Practice Address - Street 1:5301 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4940
Practice Address - Country:US
Practice Address - Phone:806-793-5947
Practice Address - Fax:806-793-4544
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist