Provider Demographics
NPI:1033310479
Name:KIM, LISA M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:65545 BARRENS DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6430
Mailing Address - Country:US
Mailing Address - Phone:574-533-9727
Mailing Address - Fax:
Practice Address - Street 1:1615 WINSTED DR
Practice Address - Street 2:SUITE 3
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4696
Practice Address - Country:US
Practice Address - Phone:574-534-4648
Practice Address - Fax:574-537-9048
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002626A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant