Healthcare Provider Details

I. General information

NPI: 1205141199
Provider Name (Legal Business Name): LISA LYNN HURST C.O.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7377 DEERTRACK CT
YPSILANTI MI
48197-9591
US

IV. Provider business mailing address

7377 DEERTRACK CT
YPSILANTI MI
48197-9591
US

V. Phone/Fax

Practice location:
  • Phone: 734-834-4216
  • Fax:
Mailing address:
  • Phone: 734-834-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202006537
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: