Basic Information
| Provider Information | |||||||||
| NPI: | 1952805590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTRUP | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 COMPASS RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600268001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 W ANN ARBOR TRL STE 220 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT.0004576 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT.60913624 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT.16182 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.