=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396550968
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA CUN LAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10459 CHURCH ST
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-7491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-692-7360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1923 SALTO DR
-----------------------------------------------------
City | HACIENDA HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91745-4210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-244-1940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 312739
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------