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NPI Code Detail

MEDICARE: LISA ANN OTTERBEINBOLEK MSPT

MEDICARE: LISA ANN OTTERBEINBOLEK MSPT
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
1225100000XPhysical Therapist5501012378MI

General Provider Information

NPI Number : 1619191756
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA ANN OTTERBEINBOLEK MSPT
Provider Business Mailing Address
First Line : 1377 MOTOR PKWY
Second Line : STE 307
City : ISLANDIA
State : NY
Zip : 11749-5258
Country : US
Telephone Number : 631-580-5200
Fax Number :
Provider Business Practice Location Address
First Line : 25 CONRAN DR
Second Line :
City : COOPERSVILLE
State : MI
Zip : 49404-1366
Country : US
Telephone Number : 616-997-6172
Fax Number : 616-997-6178
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/12/2007
Last Update Date : 01/30/2025

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