MEDICARE: LISA CLARKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT872383	DC
2	225100000X	Physical Therapist	2305208849	VA

General Provider Information

NPI Number	:	1750790283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA CLARKSON

Provider Business Mailing Address
First Line	:	408 HIGUERA ST STE 200
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-6135
Country	:	US
Telephone Number	:	805-788-0805
Fax Number	:	805-788-0845

Provider Business Practice Location Address
First Line	:	410 S MAPLE AVE STE 100
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-4246
Country	:	US
Telephone Number	:	703-988-6010
Fax Number	:	703-526-0430

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2014
Last Update Date	:	01/26/2024

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Directions to “ LISA CLARKSON ” Practice Location

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