Provider Demographics
NPI:1740268838
Name:DEWEESE, LISA M (OTR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DEWEESE
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 1:38 MUSHRALL LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04472-4107
Mailing Address - Country:US
Mailing Address - Phone:207-951-3925
Mailing Address - Fax:
Practice Address - Street 1:587 N DEER ISLE RD
Practice Address - Street 2:
Practice Address - City:DEER ISLE
Practice Address - State:ME
Practice Address - Zip Code:04627-3438
Practice Address - Country:US
Practice Address - Phone:207-951-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV878225X00000X
ME2776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2776OtherME BOARD OF OT
WV878OtherWV BOARD OF OT
WV7501065000Medicaid
WV7501065000Medicaid
WV1037690001Medicare NSC
WV9301591Medicare PIN