Healthcare Provider Details

I. General information

NPI: 1093202145
Provider Name (Legal Business Name): LISA FOLSOM PHYSICAL THERAPY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9935 RED ARROW HWY
BRIDGMAN MI
49106-9002
US

IV. Provider business mailing address

PO BOX 126
HARBERT MI
49115-0126
US

V. Phone/Fax

Practice location:
  • Phone: 269-465-3017
  • Fax:
Mailing address:
  • Phone: 312-369-9629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501005065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: