Healthcare Provider Details

I. General information

NPI: 1720438997
Provider Name (Legal Business Name): LISA MICKELSEN-STRUBEL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 5TH ST SW
HURON SD
57350
US

IV. Provider business mailing address

150 5TH ST SW
HURON SD
57350
US

V. Phone/Fax

Practice location:
  • Phone: 605-353-6997
  • Fax:
Mailing address:
  • Phone: 605-353-6997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0066
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number0066
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: