MEDICARE: MS. LISA MICHELLE MASSEY MOT, OTR, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	111105	TX

General Provider Information

NPI Number	:	1528209822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MICHELLE MASSEY MOT, OTR, CLT

Provider Business Mailing Address
First Line	:	201 W CRAIG PL
Second Line	:	UNIT E
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-3470
Country	:	US
Telephone Number	:	210-833-5188
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 W CRAIG PL
Second Line	:	UNIT E
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-3470
Country	:	US
Telephone Number	:	210-833-5188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2009
Last Update Date	:	03/16/2009

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