Healthcare Provider Details

I. General information

NPI: 1962980334
Provider Name (Legal Business Name): LISA MICHELLE GLASS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2018
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BRIGHAM ST
PLAINWELL MI
49080-1587
US

IV. Provider business mailing address

65 2ND ST
PLAINWELL MI
49080-9550
US

V. Phone/Fax

Practice location:
  • Phone: 269-685-9805
  • Fax:
Mailing address:
  • Phone: 734-255-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5201006690
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: