Provider Demographics
NPI:1588677918
Name:CHACKO, LISA (LPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MARCUS HOOK
Mailing Address - State:PA
Mailing Address - Zip Code:19061-4513
Mailing Address - Country:US
Mailing Address - Phone:610-859-8850
Mailing Address - Fax:610-859-7876
Practice Address - Street 1:2966 STREET RD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2604
Practice Address - Country:US
Practice Address - Phone:215-639-2639
Practice Address - Fax:215-929-2464
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0176278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30052556OtherKEYSTONE MERCY
PA1023356770001Medicaid
PA2579694000OtherIBC
PA1023356770001Medicaid
PA30052556OtherKEYSTONE MERCY