Healthcare Provider Details

I. General information

NPI: 1801547518
Provider Name (Legal Business Name): MARISSA ELIZABETH LOBERGER OTR / L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 N MILWAUKEE ST UNIT 214
MILWAUKEE WI
53202-3153
US

IV. Provider business mailing address

1108 N MILWAUKEE ST UNIT 214
MILWAUKEE WI
53202-3153
US

V. Phone/Fax

Practice location:
  • Phone: 920-639-8409
  • Fax:
Mailing address:
  • Phone: 920-639-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number056.01.4660
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: