Basic Information
Provider Information | |||||||||
NPI: | 1275003584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOVER | ||||||||
FirstName: | LISA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 CHRISTIANS DR | ||||||||
Address2: |   | ||||||||
City: | HANOVER | ||||||||
State: | PA | ||||||||
PostalCode: | 173318467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4435707302 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 197 THOMAS JOHNSON DR STE B | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217024314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016621997 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2018 | ||||||||
LastUpdateDate: | 11/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A2166 | MD | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   | 225200000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | A2166 | 01 | MD | MARYLAND PTA LICENSE | OTHER |