Provider Demographics
NPI:1003939166
Name:WALTER, LISA ANN (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:WALTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1240
Mailing Address - Country:US
Mailing Address - Phone:317-258-2610
Mailing Address - Fax:317-569-9796
Practice Address - Street 1:1822 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1240
Practice Address - Country:US
Practice Address - Phone:317-258-2610
Practice Address - Fax:317-569-9796
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001595A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200710230 AOtherPROVIDER NUMBER