Healthcare Provider Details

I. General information

NPI: 1639912298
Provider Name (Legal Business Name): LISA KOTULA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25912 ASHBY DR
HARRISON TWP MI
48045-3081
US

IV. Provider business mailing address

25912 ASHBY DR
HARRISON TWP MI
48045-3081
US

V. Phone/Fax

Practice location:
  • Phone: 586-242-6623
  • Fax:
Mailing address:
  • Phone: 586-242-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704212792
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: