=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558825000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE MAYS PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2019
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3315 E MICHIGAN AVE STE 4
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-4649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-364-8600
-----------------------------------------------------
Fax | 517-364-8625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7353 DELTA RIVER DR
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48906-9042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-869-5831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 5502005067
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------