Provider Demographics
NPI:1861726705
Name:WOOD, LISA M
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L, LPN
Mailing Address - Street 1:577 GLEASON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-4707
Mailing Address - Country:US
Mailing Address - Phone:321-249-9443
Mailing Address - Fax:
Practice Address - Street 1:577 GLEASON ST
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-4707
Practice Address - Country:US
Practice Address - Phone:321-249-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10864224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant