Basic Information
| Provider Information | |||||||||
| NPI: | 1093202145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOLSOM | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 126 | ||||||||
| Address2: | |||||||||
| City: | HARBERT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491150126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123699629 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9935 RED ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | BRIDGMAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491069002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694653017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501005065 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501005065 | 01 | MI | PHYSICAL THERAPY LICENSE | OTHER |