Healthcare Provider Details

I. General information

NPI: 1023581162
Provider Name (Legal Business Name): LISA BENO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 LEMAY FERRY RD
SAINT LOUIS MO
63125-4535
US

IV. Provider business mailing address

14918 GREENBERRY HILL CT
CHESTERFIELD MO
63017-7705
US

V. Phone/Fax

Practice location:
  • Phone: 314-339-7430
  • Fax: 314-449-9173
Mailing address:
  • Phone: 404-375-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number116837
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: