Healthcare Provider Details

I. General information

NPI: 1598085730
Provider Name (Legal Business Name): LISA A WEATHERS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 S COLORADO ST SUITE A
GREENVILLE MS
38703-7275
US

IV. Provider business mailing address

1707 S COLORADO ST SUITE A
GREENVILLE MS
38703-7275
US

V. Phone/Fax

Practice location:
  • Phone: 662-335-8332
  • Fax: 662-335-8852
Mailing address:
  • Phone: 662-335-8332
  • Fax: 662-335-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT4686
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: