Healthcare Provider Details

I. General information

NPI: 1558846287
Provider Name (Legal Business Name): LISA RENEA ROUNDTREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 S PARK AVE
DENISON TX
75020-7342
US

IV. Provider business mailing address

360 WILLIS RD
MEAD OK
73449-5265
US

V. Phone/Fax

Practice location:
  • Phone: 903-327-8537
  • Fax:
Mailing address:
  • Phone: 903-271-8281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number209322
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: