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Individual

LISA MARIE SHIMP

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
COTA/L

Contact information

Practice address
111 LAKESIDE DR NE, GRAND RAPIDS, MI 49503-3811
(616) 588-1645
Mailing address
9262 160TH AVE, WEST OLIVE, MI 49460-9193
(616) 990-0970

Taxonomy

Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5202007926
MI

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
235310
MI
05
235378
MI
05
235401
MI
05
235667
MI
Enumeration date
10/09/2018
Last updated
10/09/2018
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