Provider Demographics
NPI:1245563196
Name:DODGE, LISA KAREN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KAREN
Last Name:DODGE
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 1:571 75TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-3819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:571 75TH ST
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005-3819
Practice Address - Country:US
Practice Address - Phone:715-268-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3790-046172M00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No305S00000XManaged Care OrganizationsPoint of Service