Healthcare Provider Details

I. General information

NPI: 1174734222
Provider Name (Legal Business Name): LISA K CARROLL OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 JESSUP RD
PAULSBORO NJ
08066-1921
US

IV. Provider business mailing address

110 WYCOMBE CT
WOODBURY NJ
08096-4228
US

V. Phone/Fax

Practice location:
  • Phone: 856-848-9551
  • Fax:
Mailing address:
  • Phone: 856-227-8365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00407000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: