Provider Demographics
NPI:1841618576
Name:MATHIS, LISA LYNN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LYNN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:LYNN
Other - Last Name:BANNIGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:21570 WINSHALL CT
Mailing Address - Street 2:N/A
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1234
Mailing Address - Country:US
Mailing Address - Phone:586-321-7411
Mailing Address - Fax:
Practice Address - Street 1:2222 SULLIVAN TRL
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-7958
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:610-438-2046
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003515225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist