Provider Demographics
NPI:1417303470
Name:VANDERMEER, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:VANDERMEER
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 1:8028 SARGENT RDG
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1873
Mailing Address - Country:US
Mailing Address - Phone:317-796-0671
Mailing Address - Fax:
Practice Address - Street 1:8028 SARGENT RDG
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1873
Practice Address - Country:US
Practice Address - Phone:317-796-0671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003932A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist