Provider Demographics
NPI:1154873339
Name:OWENS, LISA L
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:OWENS
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 1:421 S BOYER AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1101
Mailing Address - Country:US
Mailing Address - Phone:208-699-9635
Mailing Address - Fax:
Practice Address - Street 1:220 S DIVISION AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1759
Practice Address - Country:US
Practice Address - Phone:208-265-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-792225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid