Provider Demographics
NPI:1225289358
Name:ANGEL, LISA A (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:ANGEL
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 1:3401 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8011
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9109
Practice Address - Street 1:3401 N PERRYVILLE RD
Practice Address - Street 2:PHYSICAL THERAPY DEPT
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8011
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9109
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070016002OtherSTATE OF ILLIINOIS LICENSE
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid