Provider Demographics
NPI:1649753120
Name:SMITH, LISA LYNN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:G
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:355 DOGWOOD SOUTH LN
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8511
Mailing Address - Country:US
Mailing Address - Phone:318-489-8092
Mailing Address - Fax:
Practice Address - Street 1:355 DOGWOOD SOUTH LN
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-8511
Practice Address - Country:US
Practice Address - Phone:318-489-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ11054225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist