Provider Demographics
NPI:1184938912
Name:CARTER, LISE HELENE
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:HELENE
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISE
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 7423
Mailing Address - Street 2:
Mailing Address - City:TAHOE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96145-7423
Mailing Address - Country:US
Mailing Address - Phone:415-810-8240
Mailing Address - Fax:
Practice Address - Street 1:10587 DOUBLE R BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-8966
Practice Address - Country:US
Practice Address - Phone:415-810-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
CA8297225XP0200X
NVNV2030225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1184938912Medicaid