Provider Demographics
NPI:1992213417
Name:LISA H WISTER, INC
Entity Type:Organization
Organization Name:LISA H WISTER, INC
Other - Org Name:LISA H WISTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WISTER
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:773-230-3365
Mailing Address - Street 1:923 S HUMPHREY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1720
Mailing Address - Country:US
Mailing Address - Phone:773-230-3365
Mailing Address - Fax:855-392-6998
Practice Address - Street 1:923 S HUMPHREY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1720
Practice Address - Country:US
Practice Address - Phone:773-230-3365
Practice Address - Fax:855-392-6998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007137225XP0200X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty