Provider Demographics
NPI:1457018871
Name:HENNIN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HENNIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4358 N 1100 W
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:IN
Mailing Address - Zip Code:47943-8052
Mailing Address - Country:US
Mailing Address - Phone:219-306-2233
Mailing Address - Fax:
Practice Address - Street 1:2741 N SALISBURY ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1431
Practice Address - Country:US
Practice Address - Phone:765-463-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002556A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UNKNOWNOtherUNKNOWN