Provider Demographics
NPI:1558627208
Name:BROADFOOT, LISA BOWEN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BOWEN
Last Name:BROADFOOT
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 1:5710 WIGTON DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-4837
Mailing Address - Country:US
Mailing Address - Phone:713-721-5256
Mailing Address - Fax:
Practice Address - Street 1:5710 WIGTON DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-4837
Practice Address - Country:US
Practice Address - Phone:713-721-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1088516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist