Provider Demographics
NPI:1275994055
Name:HA, LISA (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16960 ALGONQUIN ST
Mailing Address - Street 2:APT 2-301
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3800
Mailing Address - Country:US
Mailing Address - Phone:510-590-2905
Mailing Address - Fax:
Practice Address - Street 1:17122 BEACH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5992
Practice Address - Country:US
Practice Address - Phone:714-848-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist