Provider Demographics
NPI:1285779090
Name:LISH-MITCH, ANN MARGARET (OTR)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARGARET
Last Name:LISH-MITCH
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 1:7012 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2942
Mailing Address - Country:US
Mailing Address - Phone:763-546-7221
Mailing Address - Fax:
Practice Address - Street 1:7012 30TH AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55427-2942
Practice Address - Country:US
Practice Address - Phone:763-546-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN100736OtherOT STATE LIC.