Provider Demographics
NPI:1306039888
Name:EATON, LISA JANE (MS OTR/L CAP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JANE
Last Name:EATON
Suffix:
Gender:F
Credentials:MS OTR/L CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 LANE 5
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-9740
Mailing Address - Country:US
Mailing Address - Phone:970-420-9588
Mailing Address - Fax:
Practice Address - Street 1:507 N CLARK ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1915
Practice Address - Country:US
Practice Address - Phone:970-420-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAP-190101YA0400X
171M00000X
WY686225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid
WY145664400Medicaid