Provider Demographics
NPI:1114907003
Name:DANG, LISA THU (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:THU
Last Name:DANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:THU
Other - Last Name:THAO HONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10505 19TH AVE SE
Mailing Address - Street 2:B
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4280
Mailing Address - Country:US
Mailing Address - Phone:408-570-0510
Mailing Address - Fax:408-945-4018
Practice Address - Street 1:507 SR 2
Practice Address - Street 2:E & F
Practice Address - City:SULTAN
Practice Address - State:WA
Practice Address - Zip Code:98294
Practice Address - Country:US
Practice Address - Phone:360-799-0958
Practice Address - Fax:360-799-0623
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8443814Medicaid
WAG8878936Medicare PIN