Provider Demographics
NPI:1184286007
Name:WIDMER, LISA (OTR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WIDMER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 WATER OAK
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-6517
Mailing Address - Country:US
Mailing Address - Phone:469-237-6264
Mailing Address - Fax:
Practice Address - Street 1:6530 HAWKS CREEK CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1163
Practice Address - Country:US
Practice Address - Phone:888-332-9928
Practice Address - Fax:817-810-0240
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119768225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist