Provider Demographics
NPI:1790032878
Name:KERCHENFAUT, LISA RENEE' (COTA)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:RENEE'
Last Name:KERCHENFAUT
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 1:200 MICHIGAN AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3607
Mailing Address - Country:US
Mailing Address - Phone:269-441-9306
Mailing Address - Fax:
Practice Address - Street 1:200 MICHIGAN AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3607
Practice Address - Country:US
Practice Address - Phone:269-441-9306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202002425224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant