Healthcare Provider Details

I. General information

NPI: 1740268838
Provider Name (Legal Business Name): LISA M. DEWEESE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 N DEER ISLE RD
DEER ISLE ME
04627-3438
US

IV. Provider business mailing address

38 MUSHRALL LN
ORLAND ME
04472-4107
US

V. Phone/Fax

Practice location:
  • Phone: 207-951-3925
  • Fax:
Mailing address:
  • Phone: 207-951-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number878
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2776
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: