Provider Demographics
NPI:1083204184
Name:BUSSERT, LISA RENEE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:BUSSERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 OAKLAND STOUTSVILLE RD SW
Mailing Address - Street 2:
Mailing Address - City:AMANDA
Mailing Address - State:OH
Mailing Address - Zip Code:43102-9553
Mailing Address - Country:US
Mailing Address - Phone:740-503-4092
Mailing Address - Fax:
Practice Address - Street 1:8700 OAKLAND STOUTSVILLE RD SW
Practice Address - Street 2:
Practice Address - City:AMANDA
Practice Address - State:OH
Practice Address - Zip Code:43102-9553
Practice Address - Country:US
Practice Address - Phone:740-503-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.148873.MEDS-IV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty