Provider Demographics
NPI:1750598173
Name:WILSON, LISA RENEE (COTA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:7413 PIERCE PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-4679
Mailing Address - Country:US
Mailing Address - Phone:219-736-9656
Mailing Address - Fax:
Practice Address - Street 1:7413 PIERCE PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE BRA
Practice Address - State:IN
Practice Address - Zip Code:46410-4679
Practice Address - Country:US
Practice Address - Phone:219-736-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000548A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant