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NPI Code Detail

MEDICARE: LISA OTTO M.A. CCC-SLP

MEDICARE: LISA OTTO M.A. CCC-SLP
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
1235Z00000XSpeech-Language Pathologist146.010533IL

General Provider Information

NPI Number : 1982971883
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA OTTO M.A. CCC-SLP
Provider Business Mailing Address
First Line : 1318 W WILSON AVE UNIT 3A
Second Line :
City : CHICAGO
State : IL
Zip : 60640-6243
Country : US
Telephone Number : 734-788-8771
Fax Number :
Provider Business Practice Location Address
First Line : 929 W FOSTER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60640-1491
Country : US
Telephone Number : 773-433-1800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/19/2011
Last Update Date : 03/19/2021

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