Provider Demographics
NPI:1871889477
Name:RICH, LISA RENEE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:RICH
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 1:2616 E. LAWRENCE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2023
Mailing Address - Country:US
Mailing Address - Phone:217-220-2542
Mailing Address - Fax:
Practice Address - Street 1:2616 E LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2023
Practice Address - Country:US
Practice Address - Phone:217-220-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057-001818224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant