Provider Demographics
NPI:1962980334
Name:GLASS, LISA MICHELLE (OTR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:GLASS
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 1:65 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9550
Mailing Address - Country:US
Mailing Address - Phone:734-255-7056
Mailing Address - Fax:
Practice Address - Street 1:320 BRIGHAM ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1587
Practice Address - Country:US
Practice Address - Phone:269-685-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XG0600X
MI5201006690225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology