Healthcare Provider Details

I. General information

NPI: 1972991487
Provider Name (Legal Business Name): LISA DEPAUL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

5035 RELA WAY W
QUARTZ HILL CA
93536-2511
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-8463
  • Fax:
Mailing address:
  • Phone: 734-276-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8875
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number03425
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: