Provider Demographics
NPI:1114082328
Name:RIDGEWAY, LISA (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RIDGEWAY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5357 N OSCEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1719
Mailing Address - Country:US
Mailing Address - Phone:773-774-9763
Mailing Address - Fax:
Practice Address - Street 1:6705 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5142
Practice Address - Country:US
Practice Address - Phone:630-388-6700
Practice Address - Fax:630-388-6777
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist