MEDICARE: LISA BRACHT MBA, LAT, ATC

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	2255A2300X	Athletic Trainer	36002654A	IN

General Provider Information

NPI Number	:	1780197301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BRACHT MBA, LAT, ATC

Provider Business Mailing Address
First Line	:	1518 TECUMSEH ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4248
Country	:	US
Telephone Number	:	260-409-8862
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 S CALHOUN ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2006
Country	:	US
Telephone Number	:	260-467-2653
Fax Number	:

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

Provider Enumeration Date	:	11/06/2017
Last Update Date	:	11/06/2017

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