Provider Demographics
NPI:1265027064
Name:MOHATT, LISA NICHOLLS (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICHOLLS
Last Name:MOHATT
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:PO BOX 6544
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-7100
Mailing Address - Country:US
Mailing Address - Phone:307-752-6633
Mailing Address - Fax:
Practice Address - Street 1:135 N GOULD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3927
Practice Address - Country:US
Practice Address - Phone:307-752-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist