Healthcare Provider Details

I. General information

NPI: 1942273347
Provider Name (Legal Business Name): DR. LISA VICTORIA DEPASQUALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA VICTORIA SAPP PT DSC ECS

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 GRAND AVE 400
GURNEE IL
60031-3741
US

IV. Provider business mailing address

3430 GRAND AVE 400
GURNEE IL
60031
US

V. Phone/Fax

Practice location:
  • Phone: 847-782-9860
  • Fax:
Mailing address:
  • Phone: 847-782-9860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2305003849
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5264199
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: