MEDICARE: LISA DOUGLAS MOT, OTR/L, 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	OT.007743	OH
2	225X00000X	Occupational Therapist	4031	NM
3	225X00000X	Occupational Therapist	OT20253	FL

General Provider Information

NPI Number	:	1760842215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DOUGLAS MOT, OTR/L, CLT

Provider Business Mailing Address
First Line	:	336 BROAD ST # 203
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-3006
Country	:	US
Telephone Number	:	407-293-3156
Fax Number	:	407-293-3155

Provider Business Practice Location Address
First Line	:	809 GOOD HOMES RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-6628
Country	:	US
Telephone Number	:	407-293-3156
Fax Number	:	407-293-3155

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

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	07/27/2021

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