=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912579632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCIA GRACE KISSINGER OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2021
-----------------------------------------------------
Last Update Date | 07/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 E RAWSON AVE STE 317
-----------------------------------------------------
City | OAK CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53154-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-287-0090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4434 N WILSON DR APT 3
-----------------------------------------------------
City | SHOREWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53211-1336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-659-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 7018-26
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------