Provider Demographics
NPI:1063631810
Name:PHILLIPS, LISA M (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PHILLIPS
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 1:949 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5105
Mailing Address - Country:US
Mailing Address - Phone:410-543-9000
Mailing Address - Fax:410-543-9033
Practice Address - Street 1:949 MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5105
Practice Address - Country:US
Practice Address - Phone:410-543-9000
Practice Address - Fax:410-543-9033
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD071378301Medicaid
MDS4020004OtherFEDERAL BC
MD52788301OtherCAREFIRST
MD45897OtherMAMSI
MD071378301Medicaid