Healthcare Provider Details

I. General information

NPI: 1073243762
Provider Name (Legal Business Name): DR. LISA PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
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 Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA FERNANDEZ
Title or Position: OWNER/MANAGING MEMBER
Credential:
Phone: 305-467-9421