Provider Demographics
NPI:1174782957
Name:WHITE, LISA R (MA OTR/L)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA OTR/L
Mailing Address - Street 1:15646 76TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2677
Mailing Address - Country:US
Mailing Address - Phone:763-229-9891
Mailing Address - Fax:
Practice Address - Street 1:15646 76TH PL N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2677
Practice Address - Country:US
Practice Address - Phone:763-229-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101179225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation