Provider Demographics
NPI:1154675296
Name:HULETT, LISA (OTRL)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HULETT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 NATANNA DR
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-7382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12319 HIGHLAND RD
Practice Address - Street 2:SUITE 501
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2946
Practice Address - Country:US
Practice Address - Phone:810-991-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008397225X00000X, 225XF0002X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing