Provider Demographics
NPI:1861500530
Name:HALL, LISA J (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:HALL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 COMIKEV LN
Mailing Address - Street 2:
Mailing Address - City:WINTERPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04496-3829
Mailing Address - Country:US
Mailing Address - Phone:207-941-4301
Mailing Address - Fax:207-941-4062
Practice Address - Street 1:656 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5609
Practice Address - Country:US
Practice Address - Phone:207-941-4036
Practice Address - Fax:207-941-4062
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1526Medicare ID - Type Unspecified
Q51083Medicare UPIN