Provider Demographics
NPI:1558650424
Name:PONICHTER, LISA DARLENE (MPT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DARLENE
Last Name:PONICHTER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W OAKRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2702
Mailing Address - Country:US
Mailing Address - Phone:248-321-0358
Mailing Address - Fax:
Practice Address - Street 1:455 W OAKRIDGE ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2702
Practice Address - Country:US
Practice Address - Phone:248-321-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist