Provider Demographics
NPI:1467721597
Name:GROSS, LISA ANN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:GROSS
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:W6570 HWY MM
Mailing Address - Street 2:
Mailing Address - City:ELKHART LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53020-1508
Mailing Address - Country:US
Mailing Address - Phone:920-980-9591
Mailing Address - Fax:
Practice Address - Street 1:N7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-3103
Practice Address - Country:US
Practice Address - Phone:920-893-6441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1218.67224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1218.27OtherCERTIFIED OCC THERAPIST ASSISTANT