Provider Demographics
NPI:1184178931
Name:FUNK, LISA (LPTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-3879
Mailing Address - Country:US
Mailing Address - Phone:276-773-8118
Mailing Address - Fax:276-773-2219
Practice Address - Street 1:574 E MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-3879
Practice Address - Country:US
Practice Address - Phone:276-773-8118
Practice Address - Fax:276-773-2219
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604492225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant