Provider Demographics
NPI:1538731260
Name:MICHAEL, MARY LISA (MS, OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 LANE 160 JIMMERSON LK
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-9178
Mailing Address - Country:US
Mailing Address - Phone:260-243-0816
Mailing Address - Fax:
Practice Address - Street 1:28100 TORCH PARKWAY, SUITE 600
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906
Practice Address - Country:US
Practice Address - Phone:765-427-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001433A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist