Provider Demographics
NPI:1982971883
Name:OTTO, LISA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:PRZYBYLSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:1318 W WILSON AVE UNIT 3A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6243
Mailing Address - Country:US
Mailing Address - Phone:734-788-8771
Mailing Address - Fax:
Practice Address - Street 1:929 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1491
Practice Address - Country:US
Practice Address - Phone:773-433-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist