Provider Demographics
NPI:1033121868
Name:HALL, MARY LISA (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LISA
Last Name:HALL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MCGAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:245 JENNIFER LYNN DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:270-705-5898
Mailing Address - Fax:270-554-3136
Practice Address - Street 1:2500 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:PAUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-554-3135
Practice Address - Fax:270-554-3136
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11856022OtherCAQH
KYP00417118OtherMEDICARE RAILROAD
KY7100041860Medicaid
11856022OtherCAQH