Provider Demographics
NPI:1407492580
Name:LAGOMARCINO, LISA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAGOMARCINO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 SALIX CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8955
Mailing Address - Country:US
Mailing Address - Phone:630-632-3524
Mailing Address - Fax:
Practice Address - Street 1:2533 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7166
Practice Address - Country:US
Practice Address - Phone:773-472-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.024660OtherMEDICARE
IL070024660OtherMEDICARE