Healthcare Provider Details

I. General information

NPI: 1316014608
Provider Name (Legal Business Name): LISA ELLEN CYZNER PHD OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 CARMEL RD SUITE 101
CHARLOTTE NC
28226-8279
US

IV. Provider business mailing address

6401 CARMEL RD SUITE 101
CHARLOTTE NC
28226-8279
US

V. Phone/Fax

Practice location:
  • Phone: 704-542-9473
  • Fax: 704-752-4348
Mailing address:
  • Phone: 704-542-9473
  • Fax: 704-752-4348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number4095
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: