Provider Demographics
NPI:1083985691
Name:HANSEN, LISA LIND (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LIND
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MELISA
Other - Middle Name:LIND
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:3719 EDGEHILL DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1972
Mailing Address - Country:US
Mailing Address - Phone:678-438-4570
Mailing Address - Fax:
Practice Address - Street 1:16600 W SPRAGUE RD
Practice Address - Street 2:SUITE 365
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-6318
Practice Address - Country:US
Practice Address - Phone:216-227-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA06855225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH225200000XMedicaid
OH225200000XMedicaid