Provider Demographics
NPI:1083715619
Name:VIS, LISA J (MSPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:VIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-281-1144
Mailing Address - Fax:616-281-1221
Practice Address - Street 1:5570 WILSON AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-594-2000
Practice Address - Fax:616-594-2004
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-11-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIL742129225100000X
MI5501011269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN74750004Medicare PIN