Provider Demographics
NPI:1083937940
Name:LIESER, KRISTA M (OT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:LIESER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1306 GEMINI CIR
Practice Address - Street 2:SUITE 3
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1694
Practice Address - Country:US
Practice Address - Phone:815-431-9980
Practice Address - Fax:815-431-9981
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-002942225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00855683OtherMEDICARE RR
ILIL3585006Medicare PIN