=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851571863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ANN GUST P. T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2007
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29301 N DIXIE RANCH RD
-----------------------------------------------------
City | LACOMBE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70445-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-871-4114
-----------------------------------------------------
Fax | 985-871-4130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2290
-----------------------------------------------------
City | LACOMBE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70445-2290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-871-4114
-----------------------------------------------------
Fax | 985-871-4130
-----------------------------------------------------
=====================================================
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 | 00354R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------