Provider Demographics
NPI:1063660934
Name:OBRECHT, LISA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:OBRECHT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:840 E MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3293
Mailing Address - Country:US
Mailing Address - Phone:517-816-4488
Mailing Address - Fax:517-327-9597
Practice Address - Street 1:840 E MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3293
Practice Address - Country:US
Practice Address - Phone:517-816-4488
Practice Address - Fax:517-327-9597
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750004Medicare PIN