MEDICARE: MS. LISA YVETTE OTTENHOFF LMSW, ACSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801065659	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MI3674	OTHER	MI	MEDICARE PTAN

General Provider Information

NPI Number	:	1083613624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA YVETTE OTTENHOFF LMSW, ACSW

Provider Business Mailing Address
First Line	:	391 S SHORE DR STE 214
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-5446
Country	:	US
Telephone Number	:	269-964-0153
Fax Number	:	855-877-5812

Provider Business Practice Location Address
First Line	:	391 S SHORE DR STE 214
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-5446
Country	:	US
Telephone Number	:	269-964-0153
Fax Number	:	855-877-5812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2005
Last Update Date	:	06/15/2023

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