Basic Information
| Provider Information | |||||||||
| NPI: | 1912614686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDDER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PTA, LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E MAIN ST APT 312 | ||||||||
| Address2: | |||||||||
| City: | WAUNAKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535971481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156081577 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5249 E TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082229777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2022 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 15749 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225200000X | 2260 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.