Provider Demographics
NPI:1275681793
Name:DECONINCK, LISA (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DECONINCK
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 1:1980 HILLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304
Mailing Address - Country:US
Mailing Address - Phone:248-646-1916
Mailing Address - Fax:
Practice Address - Street 1:1845 LIVERNOIS
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-362-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist