Provider Demographics
NPI:1437740503
Name:LEASE, CORISSA M
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:M
Last Name:LEASE
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 1:308 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1218 STATE ST
Practice Address - Street 2:
Practice Address - City:BLACK EARTH
Practice Address - State:WI
Practice Address - Zip Code:53515
Practice Address - Country:US
Practice Address - Phone:608-767-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant