Provider Demographics
NPI:1346670643
Name:PACK, LISA (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9562 LOVELESS RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43044-9535
Mailing Address - Country:US
Mailing Address - Phone:937-631-7249
Mailing Address - Fax:
Practice Address - Street 1:1600 SAINT PARIS PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1226
Practice Address - Country:US
Practice Address - Phone:937-399-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant