Healthcare Provider Details

I. General information

NPI: 1174782957
Provider Name (Legal Business Name): LISA R WHITE MA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA R WHITE MA OTR/L

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15646 76TH PL N
MAPLE GROVE MN
55311-2677
US

IV. Provider business mailing address

15646 76TH PL N
MAPLE GROVE MN
55311-2677
US

V. Phone/Fax

Practice location:
  • Phone: 763-229-9891
  • Fax:
Mailing address:
  • Phone: 763-229-9891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number101179
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: