Healthcare Provider Details

I. General information

NPI: 1053441790
Provider Name (Legal Business Name): LISA ELLEN CROWNER P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTRAL
BAYARD NM
88023
US

IV. Provider business mailing address

1 FOREST RIDGE TRAIL
SILVER CITY NM
88061
US

V. Phone/Fax

Practice location:
  • Phone: 505-537-4000
  • Fax: 505-537-3921
Mailing address:
  • Phone: 505-537-5825
  • Fax: 505-537-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1269
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: