Provider Demographics
NPI:1285164558
Name:LUTES, LISA MARIE I (OTR)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:LUTES
Suffix:I
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 1:21104 FRAZHO ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3125
Mailing Address - Country:US
Mailing Address - Phone:586-489-1211
Mailing Address - Fax:
Practice Address - Street 1:41155 POND VIEW DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3891
Practice Address - Country:US
Practice Address - Phone:586-739-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002140225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty