Provider Demographics
NPI:1891030953
Name:PETROFF, LISA HIGDON
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HIGDON
Last Name:PETROFF
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 1:1200 EARHART RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2768
Mailing Address - Country:US
Mailing Address - Phone:734-929-6721
Mailing Address - Fax:
Practice Address - Street 1:1200 EARHART RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2768
Practice Address - Country:US
Practice Address - Phone:734-929-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006617225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist