MEDICARE: MRS. LISBETH WISEMAN

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	224Z00000X	Occupational Therapy Assistant	1171	OK

General Provider Information

NPI Number	:	1790076644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISBETH WISEMAN

Provider Business Mailing Address
First Line	:	2401 NW 23RD ST STE 2D
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-2420
Country	:	US
Telephone Number	:	405-550-4910
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 NW 23RD ST STE 2D
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-2420
Country	:	US
Telephone Number	:	405-550-4910
Fax Number	:

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

Provider Enumeration Date	:	04/27/2011
Last Update Date	:	07/22/2022

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