Provider Demographics
NPI:1841592409
Name:MOEN, LISA ELANE (OT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELANE
Last Name:MOEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19217 36TH AVE W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5751
Mailing Address - Country:US
Mailing Address - Phone:425-670-9995
Mailing Address - Fax:
Practice Address - Street 1:19217 36TH AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5751
Practice Address - Country:US
Practice Address - Phone:425-670-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 00001157225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation