Provider Demographics
NPI:1962265421
Name:LISS, REGAN KAELLE (OT)
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:KAELLE
Last Name:LISS
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 1:1860 N 95TH LN STE 105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4333
Mailing Address - Country:US
Mailing Address - Phone:480-429-5266
Mailing Address - Fax:480-429-5297
Practice Address - Street 1:10304 N HAYDEN RD STE 115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1218
Practice Address - Country:US
Practice Address - Phone:480-429-5266
Practice Address - Fax:480-429-5297
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009566225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist