Provider Demographics
NPI:1912461229
Name:HERBERT, LISA M (OTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HERBERT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 S RIVER RD
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2909
Practice Address - Country:US
Practice Address - Phone:810-329-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002914208100000X, 2081P0010X, 225XP0200X
MI52010022914225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619941333Medicaid