Healthcare Provider Details

I. General information

NPI: 1912614686
Provider Name (Legal Business Name): LISA LYNN WIDDER PTA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5249 E TERRACE DR
MADISON WI
53718-8339
US

IV. Provider business mailing address

301 E MAIN ST APT 312
WAUNAKEE WI
53597-1481
US

V. Phone/Fax

Practice location:
  • Phone: 608-222-9777
  • Fax:
Mailing address:
  • Phone: 815-608-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2260
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15749
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: