Provider Demographics
NPI:1093945982
Name:HEARLEY, LISA CHRISTINE (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:HEARLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 E 10 MILE RD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3355
Mailing Address - Country:US
Mailing Address - Phone:586-279-3250
Mailing Address - Fax:
Practice Address - Street 1:17200 E 10 MILE RD
Practice Address - Street 2:SUITE 135
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3355
Practice Address - Country:US
Practice Address - Phone:586-279-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-26
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006734224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant