Provider Demographics
NPI:1225214687
Name:EVERETT-BRIDGEWATER, LISA SUSAN (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:SUSAN
Last Name:EVERETT-BRIDGEWATER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 WATERFALL CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-6718
Mailing Address - Country:US
Mailing Address - Phone:775-626-7608
Mailing Address - Fax:
Practice Address - Street 1:3636 WATERFALL CT
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-6718
Practice Address - Country:US
Practice Address - Phone:775-626-7608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist