MEDICARE: LISA ANNE CAROLLO MS,OTL

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	5201003009	MI

General Provider Information

NPI Number	:	1336626886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANNE CAROLLO MS,OTL

Provider Business Mailing Address
First Line	:	506 W B ST
Second Line	:
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-2722
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 US HIGHWAY 2
Second Line	:
City	:	CRYSTAL FALLS
State	:	MI
Zip	:	49920-9633
Country	:	US
Telephone Number	:	906-874-1444
Fax Number	:

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

Provider Enumeration Date	:	07/26/2018
Last Update Date	:	07/26/2018

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