Provider Demographics
NPI:1366690570
Name:IMBODY, LISA LAYELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LAYELLE
Last Name:IMBODY
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 1:424 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-1958
Mailing Address - Country:US
Mailing Address - Phone:260-402-2334
Mailing Address - Fax:
Practice Address - Street 1:424 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-1958
Practice Address - Country:US
Practice Address - Phone:260-402-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002665A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant