Provider Demographics
NPI:1649455130
Name:VAN GORDER, LISA (OTR/L, CEIS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:VAN GORDER
Suffix:
Gender:F
Credentials:OTR/L, CEIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:MA
Practice Address - Zip Code:01749-1459
Practice Address - Country:US
Practice Address - Phone:978-568-8800
Practice Address - Fax:978-568-8877
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8197225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics