Provider Demographics
NPI:1992974802
Name:TEBO, LISA RAE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RAE
Last Name:TEBO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:RAE
Other - Last Name:SHELLHAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-1075
Mailing Address - Country:US
Mailing Address - Phone:518-359-9495
Mailing Address - Fax:
Practice Address - Street 1:5 CHERRY LN
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-1075
Practice Address - Country:US
Practice Address - Phone:518-359-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006114-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist