Healthcare Provider Details

I. General information

NPI: 1376394221
Provider Name (Legal Business Name): LISA MARIE VENETTIS OTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 22 MILE RD
SHELBY TWP MI
48317-2307
US

IV. Provider business mailing address

20728 GREEN CT
GROSSE POINTE WOODS MI
48236-1459
US

V. Phone/Fax

Practice location:
  • Phone: 586-580-5500
  • Fax:
Mailing address:
  • Phone: 586-770-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5202007469
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: