Basic Information
| Provider Information | |||||||||
| NPI: | 1245552298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | P.T.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623066319 | ||||||||
| FaxNumber: | 2623062964 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 E PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530955444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623066319 | ||||||||
| FaxNumber: | 2623062964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 378 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 378-19 | 01 | WI | STATE LICENSE | OTHER |