Provider Demographics
NPI:1154013431
Name:POWLEN, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:POWLEN
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 1:507 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IN
Mailing Address - Zip Code:46929-1347
Mailing Address - Country:US
Mailing Address - Phone:765-586-3036
Mailing Address - Fax:
Practice Address - Street 1:507 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:46929-1347
Practice Address - Country:US
Practice Address - Phone:765-586-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist