Provider Demographics
NPI:1184715492
Name:LILLIS, AGUSTA (OTR)
Entity type:Individual
Prefix:
First Name:AGUSTA
Middle Name:
Last Name:LILLIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:AGUSTA
Other - Middle Name:
Other - Last Name:HENNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:910 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4240
Mailing Address - Country:US
Mailing Address - Phone:715-379-1268
Mailing Address - Fax:
Practice Address - Street 1:910 SUMMER ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4240
Practice Address - Country:US
Practice Address - Phone:715-379-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3653225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6402271OtherMEDICA
MN017M7LIOtherBCBS
WI41810700Medicaid
MN6402271OtherMEDICA