Provider Demographics
NPI:1164077723
Name:MILLER, LISA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 MONCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7206
Mailing Address - Country:US
Mailing Address - Phone:432-741-5527
Mailing Address - Fax:
Practice Address - Street 1:1012 W MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-3341
Practice Address - Country:US
Practice Address - Phone:432-334-0900
Practice Address - Fax:432-590-2609
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2150086225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant