Provider Demographics
NPI:1265671994
Name:RAVALLI, LISA (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RAVALLI
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 JULIO PL
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-5012
Mailing Address - Country:US
Mailing Address - Phone:619-449-1877
Mailing Address - Fax:858-279-5303
Practice Address - Street 1:3959 RUFFIN RD
Practice Address - Street 2:SUITE F
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1830
Practice Address - Country:US
Practice Address - Phone:858-279-5570
Practice Address - Fax:858-279-5303
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 35433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist