Healthcare Provider Details

I. General information

NPI: 1649715871
Provider Name (Legal Business Name): LISA THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2016
Last Update Date: 12/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W NORTH 12TH ST
SHELBYVILLE IL
62565-9554
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2111
  • Fax:
Mailing address:
  • Phone: 971-206-5202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.007630
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: