Provider Demographics
NPI:1861228579
Name:LIS, NICO (OTR)
Entity type:Individual
Prefix:
First Name:NICO
Middle Name:
Last Name:LIS
Suffix:
Gender:X
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 62ND AVE NE STE 202
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-8173
Mailing Address - Country:US
Mailing Address - Phone:206-325-8477
Mailing Address - Fax:
Practice Address - Street 1:7821 62ND AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-8173
Practice Address - Country:US
Practice Address - Phone:206-325-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61571356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist