Basic Information
| Provider Information | |||||||||
| NPI: | 1730239807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOLGAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHINGLER | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6508 GUNN HIGHWAY | ||||||||
| Address2: | INDEPENDENT LIVING INC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 6508 GUNN HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5838 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 354737 | 01 | FL | WELLCARE | OTHER | Y020K | 01 | FL | BCBS | OTHER | 11173401 | 01 | FL | CITRUS HLC | OTHER |