Provider Demographics
NPI:1689100877
Name:LISBOA, MARLEY H (OT)
Entity Type:Individual
Prefix:
First Name:MARLEY
Middle Name:H
Last Name:LISBOA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 BALBOA BLVD.
Mailing Address - Street 2:504
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:818-363-3000
Mailing Address - Fax:
Practice Address - Street 1:3605 LONG BEACH BLVD.
Practice Address - Street 2:301
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807
Practice Address - Country:US
Practice Address - Phone:818-363-3066
Practice Address - Fax:888-833-2881
Is Sole Proprietor?:No
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist