Basic Information
| Provider Information | |||||||||
| NPI: | 1548338734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TELLUP | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 946 CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210783628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105831515 | ||||||||
| FaxNumber: | 4105832491 | ||||||||
| Practice Location | |||||||||
| Address1: | 1026 CROMWELL BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212863308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105831515 | ||||||||
| FaxNumber: | 4105832491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 17635 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.