Provider Demographics
NPI:1578082194
Name:WIMBERLY, LORISSA L (PT)
Entity Type:Individual
Prefix:
First Name:LORISSA
Middle Name:L
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 SPRING PEONY CT
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-8937
Mailing Address - Country:US
Mailing Address - Phone:512-670-9978
Mailing Address - Fax:
Practice Address - Street 1:101 PARK ST
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-4103
Practice Address - Country:US
Practice Address - Phone:512-846-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1134013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist