MEDICARE: LISA ANDERSON OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	11227	CA

General Provider Information

NPI Number	:	1265738025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANDERSON OT

Provider Business Mailing Address
First Line	:	1780 KETTNER BLVD
Second Line	:	#315
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2551
Country	:	US
Telephone Number	:	619-795-3840
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 KETTNER BLVD
Second Line	:	UNIT 315
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2553
Country	:	US
Telephone Number	:	619-795-3840
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	11/07/2016

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