Provider Demographics
NPI:1598085730
Name:WEATHERS, LISA A (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WEATHERS
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 1:1707 S COLORADO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7275
Mailing Address - Country:US
Mailing Address - Phone:662-335-8332
Mailing Address - Fax:662-335-8852
Practice Address - Street 1:1707 S COLORADO ST
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7275
Practice Address - Country:US
Practice Address - Phone:662-335-8332
Practice Address - Fax:662-335-8852
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT46862251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015486Medicaid
MS640925683OtherBCBS
MS09015486Medicaid