Healthcare Provider Details

I. General information

NPI: 1689932634
Provider Name (Legal Business Name): LISA BOYD PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 S NATIONAL AVE STE 302
SPRINGFIELD MO
65804-2213
US

IV. Provider business mailing address

1911 S NATIONAL AVE STE 302
SPRINGFIELD MO
65804-2213
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-4164
  • Fax: 417-881-1727
Mailing address:
  • Phone: 417-881-4164
  • Fax: 417-881-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2012012667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: