Provider Demographics
NPI:1376394221
Name:VENETTIS, LISA MARIE (OTAL)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:VENETTIS
Suffix:
Gender:F
Credentials:OTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20728 GREEN CT
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1459
Mailing Address - Country:US
Mailing Address - Phone:586-770-3507
Mailing Address - Fax:
Practice Address - Street 1:7401 22 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-2307
Practice Address - Country:US
Practice Address - Phone:586-580-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007469225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology