Provider Demographics
NPI:1609892843
Name:HAAS, LISA KARIN (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KARIN
Last Name:HAAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 IDAHO AVE
Mailing Address - Street 2:#6
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2667
Mailing Address - Country:US
Mailing Address - Phone:310-453-1969
Mailing Address - Fax:310-453-1975
Practice Address - Street 1:1708 19TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4418
Practice Address - Country:US
Practice Address - Phone:310-453-1969
Practice Address - Fax:310-453-1975
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT 22415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT22415OtherPT LICENCE NUMBER