Provider Demographics
NPI:1275003584
Name:DOVER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DOVER
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 1:15 CHRISTIANS DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-8467
Mailing Address - Country:US
Mailing Address - Phone:443-570-7302
Mailing Address - Fax:
Practice Address - Street 1:197 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4314
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2166225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA2166OtherMARYLAND PTA LICENSE