Provider Demographics
NPI:1588998793
Name:BAILEY, LISA JAE (OT/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JAE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JAE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT/L
Mailing Address - Street 1:1403 W IRON SPRINGS RD LOT 64
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3308
Mailing Address - Country:US
Mailing Address - Phone:480-528-7294
Mailing Address - Fax:
Practice Address - Street 1:1045 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1662
Practice Address - Country:US
Practice Address - Phone:805-287-2944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2413225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist