Provider Demographics
NPI:1174666143
Name:SHERWOOD, LISA GAETANA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GAETANA
Last Name:SHERWOOD
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 1:30249 SIERRA MADRE DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-7311
Mailing Address - Country:US
Mailing Address - Phone:951-699-3340
Mailing Address - Fax:
Practice Address - Street 1:25405 HANCOCK AVE STE 200
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5978
Practice Address - Country:US
Practice Address - Phone:951-506-3001
Practice Address - Fax:951-506-3002
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA 6807225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant