Provider Demographics
NPI:1124317763
Name:CLEMENTS, LISA MARY (OTR)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARY
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20665 KIRBY AVE N
Mailing Address - Street 2:
Mailing Address - City:SCANDIA
Mailing Address - State:MN
Mailing Address - Zip Code:55073-9521
Mailing Address - Country:US
Mailing Address - Phone:651-433-3582
Mailing Address - Fax:
Practice Address - Street 1:1119 OWENS ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4316
Practice Address - Country:US
Practice Address - Phone:651-439-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101899225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist