Basic Information
| Provider Information | |||||||||
| NPI: | 1588677918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHACKO | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 2966 STREET RD | ||||||||
| Address2: | |||||||||
| City: | BENSALEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190202604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156392639 | ||||||||
| FaxNumber: | 2159292464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 02/02/2011 | ||||||||
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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 | PT0176278 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30052556 | 01 | PA | KEYSTONE MERCY | OTHER | 1023356770001 | 05 | PA | MEDICAID | 2579694000 | 01 | PA | IBC | OTHER |