Provider Demographics
NPI:1275937096
Name:SPROUSE, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SPROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:GORMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4458
Mailing Address - Country:US
Mailing Address - Phone:814-941-7708
Mailing Address - Fax:814-941-7708
Practice Address - Street 1:3200 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4458
Practice Address - Country:US
Practice Address - Phone:814-941-7708
Practice Address - Fax:814-941-7708
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist