Provider Demographics
NPI:1831292739
Name:WIXON, LISA (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WIXON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:SD
Mailing Address - Zip Code:57014-2202
Mailing Address - Country:US
Mailing Address - Phone:605-552-2020
Mailing Address - Fax:
Practice Address - Street 1:315 N WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070-0368
Practice Address - Country:US
Practice Address - Phone:605-326-5161
Practice Address - Fax:605-326-5734
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0374225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5833630Medicaid