Provider Demographics
NPI:1003822792
Name:WILLER, LISA M (MS PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WILLER
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-0458
Mailing Address - Country:US
Mailing Address - Phone:269-556-0930
Mailing Address - Fax:269-429-0114
Practice Address - Street 1:5709 SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-1239
Practice Address - Country:US
Practice Address - Phone:269-556-0930
Practice Address - Fax:269-429-0114
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00330531OtherRAILROAD MEDICARE
MIP00330531OtherRAILROAD MEDICARE