Healthcare Provider Details

I. General information

NPI: 1326652157
Provider Name (Legal Business Name): LISA KOFFINKE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EXECUTIVE DR STE 103
AURORA IL
60504-8150
US

IV. Provider business mailing address

24014 W RENWICK RD STE F
PLAINFIELD IL
60544-8708
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-4378
  • Fax: 630-515-1536
Mailing address:
  • Phone: 800-974-4378
  • Fax: 630-515-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056002290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: