Healthcare Provider Details

I. General information

NPI: 1215001938
Provider Name (Legal Business Name): LISA ANN ENTWISTLE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11097 SAINT CHARLES ROCK RD
SAINT ANN MO
63074-1509
US

IV. Provider business mailing address

11097 SAINT CHARLES ROCK RD
SAINT ANN MO
63074-1509
US

V. Phone/Fax

Practice location:
  • Phone: 314-213-8100
  • Fax: 314-213-8610
Mailing address:
  • Phone: 314-213-8100
  • Fax: 314-213-8610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number005129
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: