Healthcare Provider Details

I. General information

NPI: 1386054617
Provider Name (Legal Business Name): LISA HEPNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

IV. Provider business mailing address

2609 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

V. Phone/Fax

Practice location:
  • Phone: 231-439-3750
  • Fax:
Mailing address:
  • Phone: 231-439-3750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: