Provider Demographics
NPI:1407831639
Name:WHITTEN, LISA ANNE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:WHITTEN
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 1:1820 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-3112
Mailing Address - Country:US
Mailing Address - Phone:714-835-2223
Mailing Address - Fax:714-835-2224
Practice Address - Street 1:1820 E 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3112
Practice Address - Country:US
Practice Address - Phone:714-835-2223
Practice Address - Fax:714-835-2224
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT14910AMedicare ID - Type Unspecified