Healthcare Provider Details

I. General information

NPI: 1902399041
Provider Name (Legal Business Name): LORI ANN MIFSUD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WILLIAM CARLS DR STE 120X
COMMERCE TOWNSHIP MI
48382-2201
US

IV. Provider business mailing address

261 MACK AVE
DETROIT MI
48201-2417
US

V. Phone/Fax

Practice location:
  • Phone: 248-937-4515
  • Fax: 248-937-4518
Mailing address:
  • Phone: 734-745-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201003528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: