Provider Demographics
NPI:1326223769
Name:GOOD, LISA SHAWN (OT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SHAWN
Last Name:GOOD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SHAWN
Other - Last Name:ROSENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:870 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2192
Practice Address - Country:US
Practice Address - Phone:704-671-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15570225X00000X
NJ46TR00395500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ50858BMedicare PIN