Provider Demographics
NPI:1043580152
Name:YOUNG, LISA (MS, OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-2006
Mailing Address - Country:US
Mailing Address - Phone:414-571-5566
Mailing Address - Fax:414-571-5568
Practice Address - Street 1:3090 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1617
Practice Address - Country:US
Practice Address - Phone:414-449-4444
Practice Address - Fax:414-449-4448
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5126-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist