Provider Demographics
NPI:1154896827
Name:SHIMP, LISA MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:SHIMP
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9262 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9193
Mailing Address - Country:US
Mailing Address - Phone:616-990-0970
Mailing Address - Fax:
Practice Address - Street 1:111 LAKESIDE DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3811
Practice Address - Country:US
Practice Address - Phone:616-588-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007926224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235310Medicaid
MI235667Medicaid
MI235378Medicaid
MI235401Medicaid