Healthcare Provider Details

I. General information

NPI: 1255485199
Provider Name (Legal Business Name): LISA RENEE ANDERSON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA RENEE HARRISON LPTA

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9099A COLLINSVILLE RD
COLLINSVILLE MS
39325-9779
US

IV. Provider business mailing address

4655 TRICK TALBERT RD
BAILEY MS
39320-9602
US

V. Phone/Fax

Practice location:
  • Phone: 601-626-8885
  • Fax:
Mailing address:
  • Phone: 601-480-6936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4061
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: