Basic Information
| Provider Information | |||||||||
| NPI: | 1013169655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1837 LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | BOOTHWYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190612742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844837214 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105211331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OP006627 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 4998 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.