Provider Demographics
NPI:1194887430
Name:CARLYLE, LISA GALLEGO (OTR)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GALLEGO
Last Name:CARLYLE
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 1:2111 SPRING CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-1297
Mailing Address - Country:US
Mailing Address - Phone:561-707-9640
Mailing Address - Fax:561-557-4415
Practice Address - Street 1:2111 SPRING CT
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-1297
Practice Address - Country:US
Practice Address - Phone:561-707-9640
Practice Address - Fax:561-557-4415
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1522225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL881082600Medicaid