Provider Demographics
NPI:1891935136
Name:MANGELSDORFF, LISA MARIE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MANGELSDORFF
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14520 HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2816
Mailing Address - Country:US
Mailing Address - Phone:708-925-9922
Mailing Address - Fax:
Practice Address - Street 1:14520 HAMLIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-2816
Practice Address - Country:US
Practice Address - Phone:708-925-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057-001348224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant