Provider Demographics
NPI:1376703900
Name:SHORT, LISA LYNETTE I (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LYNETTE
Last Name:SHORT
Suffix:I
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 1:200 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-3213
Mailing Address - Country:US
Mailing Address - Phone:830-875-8457
Mailing Address - Fax:830-875-5029
Practice Address - Street 1:200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-3213
Practice Address - Country:US
Practice Address - Phone:830-875-8457
Practice Address - Fax:830-875-5029
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2052593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant