Provider Demographics
NPI:1760842215
Name:DOUGLAS, LISA (MOT, OTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MOT, OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BROAD ST # 203
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:407-293-3156
Mailing Address - Fax:407-293-3155
Practice Address - Street 1:809 GOOD HOMES RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-6628
Practice Address - Country:US
Practice Address - Phone:407-293-3156
Practice Address - Fax:407-293-3155
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.007743225X00000X
NM4031225X00000X
FLOT20253225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist