Provider Demographics
NPI:1013169655
Name:EDWARDS, LISA JANE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JANE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-2742
Mailing Address - Country:US
Mailing Address - Phone:484-483-7214
Mailing Address - Fax:
Practice Address - Street 1:105 MORTON AVE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2409
Practice Address - Country:US
Practice Address - Phone:610-521-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006627224Z00000X
NC4998224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant