Provider Demographics
NPI:1386648335
Name:CLEARY, LISA S (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:CLEARY
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 1:1480 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2721
Mailing Address - Country:US
Mailing Address - Phone:606-528-0891
Mailing Address - Fax:606-528-3449
Practice Address - Street 1:1480 18TH ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2721
Practice Address - Country:US
Practice Address - Phone:606-528-0870
Practice Address - Fax:606-528-3449
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000048717OtherANTHEM
KY650008996OtherRAILROAD MEDICARE
KY5005705Medicare ID - Type Unspecified