Healthcare Provider Details

I. General information

NPI: 1891824538
Provider Name (Legal Business Name): LISA T.P. MA OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26114 BRIDGEWATER AVE
GLEN OAKS NY
11004-1024
US

IV. Provider business mailing address

26114 BRIDGEWATER AVE
GLEN OAKS NY
11004-1024
US

V. Phone/Fax

Practice location:
  • Phone: 917-680-1650
  • Fax:
Mailing address:
  • Phone: 917-680-1650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0069241
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0069241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: