Healthcare Provider Details

I. General information

NPI: 1821859794
Provider Name (Legal Business Name): MARION ANN LISENBY MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 SHIP SHOAL WAY
VIRGINIA BEACH VA
23451-6544
US

IV. Provider business mailing address

PO BOX 1615
VIRGINIA BEACH VA
23451-9615
US

V. Phone/Fax

Practice location:
  • Phone: 757-404-0440
  • Fax: 757-524-4004
Mailing address:
  • Phone: 757-404-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3150
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number2305004732
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305004732
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305004732
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: