Provider Demographics
NPI:1568880375
Name:BENGTSON, LISA NICOLE (MS, ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:NICOLE
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-7800
Mailing Address - Country:US
Mailing Address - Phone:712-299-1134
Mailing Address - Fax:712-749-1460
Practice Address - Street 1:610 W 4TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1713
Practice Address - Country:US
Practice Address - Phone:712-749-2021
Practice Address - Fax:712-749-1460
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0007872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer