Healthcare Provider Details

I. General information

NPI: 1053088047
Provider Name (Legal Business Name): LISA LYNN HENDERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 59TH ST W
BRADENTON FL
34209-4602
US

IV. Provider business mailing address

364 STRATHAVEN DR
PELHAM AL
35124-6282
US

V. Phone/Fax

Practice location:
  • Phone: 941-761-1000
  • Fax: 941-761-1009
Mailing address:
  • Phone: 817-917-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number31390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: