Provider Demographics
NPI:1073734596
Name:KNOBLAUCH, LISA R (MOTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:KNOBLAUCH
Suffix:
Gender:F
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14340 W FIELDPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-1223
Mailing Address - Country:US
Mailing Address - Phone:414-217-1017
Mailing Address - Fax:
Practice Address - Street 1:4545 N 92ND ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53225-4807
Practice Address - Country:US
Practice Address - Phone:414-847-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4333-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40895900Medicaid