Provider Demographics
NPI:1245837129
Name:PARK, LISA MARIE (MOTR/L)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4960 W ARGYLE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-4888
Mailing Address - Country:US
Mailing Address - Phone:773-931-4822
Mailing Address - Fax:
Practice Address - Street 1:4960 W ARGYLE ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4888
Practice Address - Country:US
Practice Address - Phone:773-931-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012361225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist