Provider Demographics
NPI:1083818629
Name:PRESTON, LISA (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:PRESTON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20024 HALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-6416
Mailing Address - Country:US
Mailing Address - Phone:804-343-6121
Mailing Address - Fax:
Practice Address - Street 1:1900 COOL LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-3912
Practice Address - Country:US
Practice Address - Phone:804-343-6121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant