Provider Demographics
NPI:1205034972
Name:OVERHOLSER, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:OVERHOLSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 TIMBER WOLF TRL N
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2228
Mailing Address - Country:US
Mailing Address - Phone:507-327-3186
Mailing Address - Fax:
Practice Address - Street 1:22 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3102
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant