Provider Demographics
NPI:1518305879
Name:CUSTER, LISA (PHD, ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CHINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, ATC
Mailing Address - Street 1:306 DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7001
Mailing Address - Country:US
Mailing Address - Phone:219-309-4121
Mailing Address - Fax:
Practice Address - Street 1:306 DIXIE DR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7001
Practice Address - Country:US
Practice Address - Phone:219-309-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0040802255A2300X
MDA00011282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer