Basic Information
Provider Information | |||||||||
NPI: | 1992904825 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWLING | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4549 TIMOTHY ST SE | ||||||||
Address2: |   | ||||||||
City: | LACEY | ||||||||
State: | WA | ||||||||
PostalCode: | 985033671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602809080 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3901 CAPITAL MALL DR SW | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985028654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607096221 | ||||||||
FaxNumber: | 3603594727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2007 | ||||||||
LastUpdateDate: | 12/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008290 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 021223 | 01 | WA | LABOR AND INDUSTRIES | OTHER |