Provider Demographics
NPI:1598990335
Name:DEGENNARO, LISA (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEGENNARO
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 1:11858 RIVER HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-9432
Mailing Address - Country:US
Mailing Address - Phone:815-543-8972
Mailing Address - Fax:
Practice Address - Street 1:11858 RIVER HILLS PKWY
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-9432
Practice Address - Country:US
Practice Address - Phone:815-543-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002490224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant