Provider Demographics
NPI:1093240616
Name:LITTLE, LISA DANIELLE (COTAL)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DANIELLE
Last Name:LITTLE
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35920 UNION LAKE RD
Mailing Address - Street 2:APT 309
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-3177
Mailing Address - Country:US
Mailing Address - Phone:586-344-5434
Mailing Address - Fax:
Practice Address - Street 1:210 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1774
Practice Address - Country:US
Practice Address - Phone:248-643-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008009224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant