=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699214460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MUNSON PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2017
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 82302 HOLLIDAY RD
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70437-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-796-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9113 WARBLER AVE
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-8379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 09281R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------