Healthcare Provider Details

I. General information

NPI: 1386787448
Provider Name (Legal Business Name): LISA MICHELLE GEBHARDT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W GREEN ST
HASTINGS MI
49058-1710
US

IV. Provider business mailing address

7196 LAKE VISTA DR SW APT 2A
BYRON CENTER MI
49315-9041
US

V. Phone/Fax

Practice location:
  • Phone: 269-948-3111
  • Fax:
Mailing address:
  • Phone: 616-723-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: