Provider Demographics
NPI:1942737820
Name:VAN HEUKELOM, LISA (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAN HEUKELOM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3279
Mailing Address - Country:US
Mailing Address - Phone:701-426-0755
Mailing Address - Fax:
Practice Address - Street 1:4530 NORTHERN SKY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8534
Practice Address - Country:US
Practice Address - Phone:701-751-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1538225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist