Provider Demographics
NPI:1124426150
Name:DIAS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 HARE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03851-4716
Mailing Address - Country:US
Mailing Address - Phone:774-991-1159
Mailing Address - Fax:
Practice Address - Street 1:3 BRAZIER LN
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7095
Practice Address - Country:US
Practice Address - Phone:774-991-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NH0842224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No252Y00000XAgenciesEarly Intervention Provider Agency