MEDICARE: MRS. LISA GRANTER NEWBERRY PT

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	5501002295	MI

General Provider Information

NPI Number	:	1902863335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA GRANTER NEWBERRY PT

Provider Business Mailing Address
First Line	:	3819 4 MILE RD N
Second Line	:	SUITE D
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-9344
Country	:	US
Telephone Number	:	231-938-2839
Fax Number	:	231-938-2924

Provider Business Practice Location Address
First Line	:	3819 4 MILE RD N
Second Line	:	SUITE D
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-9344
Country	:	US
Telephone Number	:	231-938-2839
Fax Number	:	231-938-2924

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	07/08/2007

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