Provider Demographics
NPI:1417357781
Name:OTTO, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DOREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC - SLP/L
Mailing Address - Street 1:185 S MARLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3302
Mailing Address - Country:US
Mailing Address - Phone:815-462-4928
Mailing Address - Fax:
Practice Address - Street 1:185 S MARLEY RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3302
Practice Address - Country:US
Practice Address - Phone:815-462-4928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-24
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist