MEDICARE: LISA BLACKWELL

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	OC003204L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790950707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BLACKWELL

Provider Business Mailing Address
First Line	:	3006 W OXFORD ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19121-3512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3006 W OXFORD ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19121-3512
Country	:	US
Telephone Number	:	215-763-7288
Fax Number	:

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

Provider Enumeration Date	:	04/30/2008
Last Update Date	:	05/19/2008

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Directions to “ LISA BLACKWELL ” Practice Location

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