Healthcare Provider Details

I. General information

NPI: 1760407332
Provider Name (Legal Business Name): LISA MICHAUD GLENN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53880 CARMICHAEL DR
SOUTH BEND IN
46635-1567
US

IV. Provider business mailing address

53880 CARMICHAEL DR
SOUTH BEND IN
46635-1567
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-9441
  • Fax: 574-247-9442
Mailing address:
  • Phone: 574-247-9441
  • Fax: 574-247-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000545A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: