Provider Demographics
NPI:1063822039
Name:MORITZ, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MORITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20533 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9280
Mailing Address - Country:US
Mailing Address - Phone:309-314-1885
Mailing Address - Fax:
Practice Address - Street 1:20533 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9280
Practice Address - Country:US
Practice Address - Phone:309-314-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist