Healthcare Provider Details

I. General information

NPI: 1881966067
Provider Name (Legal Business Name): LISA FERNANDEZ DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA RAY MSPT

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1794 ROUND LAKE RD
INTERLOCHEN MI
49643-8435
US

IV. Provider business mailing address

1794 ROUND LAKE RD
INTERLOCHEN MI
49643-8435
US

V. Phone/Fax

Practice location:
  • Phone: 305-467-9421
  • Fax: 305-686-2397
Mailing address:
  • Phone: 305-467-9421
  • Fax: 305-686-2397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26413
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: