Provider Demographics
NPI:1265679807
Name:LIONBERGER, CALEB (PTA, ATC)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:LIONBERGER
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5188 W CAMPO BELLO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8685 W UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-7006
Practice Address - Country:US
Practice Address - Phone:623-486-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7528A225200000X
AZ11372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer