Provider Demographics
NPI:1336626886
Name:CAROLLO, LISA ANNE (MS,OTL)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:CAROLLO
Suffix:
Gender:F
Credentials:MS,OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 W B ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-2722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1523 US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-9633
Practice Address - Country:US
Practice Address - Phone:906-874-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003009261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)