Provider Demographics
NPI:1952700544
Name:PELO, LISA (ATP, OTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PELO
Suffix:
Gender:F
Credentials:ATP, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 KARA LN
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:TX
Mailing Address - Zip Code:75002-6309
Mailing Address - Country:US
Mailing Address - Phone:214-886-0522
Mailing Address - Fax:972-418-7786
Practice Address - Street 1:4009 LINDBERGH DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4343
Practice Address - Country:US
Practice Address - Phone:972-428-3739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106463225X00000X
TX84320247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010980303Medicaid