=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184110645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE POLLAUF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2018
-----------------------------------------------------
Last Update Date | 07/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5383 HESSEN RD
-----------------------------------------------------
City | CASCO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-939-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5383 HESSEN RD
-----------------------------------------------------
City | CASCO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48064-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-939-0200
-----------------------------------------------------
Fax | 586-939-2019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5201007168
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------