Healthcare Provider Details

I. General information

NPI: 1992213417
Provider Name (Legal Business Name): LISA H WISTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 S HUMPHREY AVE
OAK PARK IL
60304-1720
US

IV. Provider business mailing address

923 S HUMPHREY AVE
OAK PARK IL
60304-1720
US

V. Phone/Fax

Practice location:
  • Phone: 773-230-3365
  • Fax: 855-392-6998
Mailing address:
  • Phone: 773-230-3365
  • Fax: 855-392-6998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056007137
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number056007137
License Number StateIL

VIII. Authorized Official

Name: LISA H WISTER
Title or Position: CHIEF OFFICER
Credential: OT
Phone: 773-230-3365