Basic Information
| Provider Information | |||||||||
| NPI: | 1962947077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKWORTH | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5775 E 400 S | ||||||||
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| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467258636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602290794 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION COURT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2016 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32000932A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.