Provider Demographics
NPI:1366819591
Name:ALTENA, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ALTENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 E SAM HOUSTON PKWY S
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3959
Mailing Address - Country:US
Mailing Address - Phone:281-487-2786
Mailing Address - Fax:281-487-3054
Practice Address - Street 1:165 STEVE BARRY BLVD
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6841
Practice Address - Country:US
Practice Address - Phone:918-824-4500
Practice Address - Fax:918-824-1977
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1261196225100000X
OKCP003248T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist