Provider Demographics
NPI:1053793133
Name:GREGORY, LISA (OTR/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERRARDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25420-4317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 DRIFTWOOD DR
Practice Address - Street 2:
Practice Address - City:GERRARDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25420-4317
Practice Address - Country:US
Practice Address - Phone:304-579-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019005502225700000X
VA0119006601225X00000X
WV1765225X00000X
MD07847225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist