Provider Demographics
NPI:1215150289
Name:NOLAN, MARLISA LYNN (OTRL, CHT, CLT)
Entity type:Individual
Prefix:MRS
First Name:MARLISA
Middle Name:LYNN
Last Name:NOLAN
Suffix:
Gender:F
Credentials:OTRL, CHT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 TAHLEQUAH LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8118
Mailing Address - Country:US
Mailing Address - Phone:573-335-1069
Mailing Address - Fax:
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4910
Practice Address - Country:US
Practice Address - Phone:573-331-5153
Practice Address - Fax:573-331-5028
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032059225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist