Provider Demographics
NPI:1629306535
Name:LISS, ILEANA I (PT)
Entity Type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:I
Last Name:LISS
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 1:17915 SOUTER LN
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7887
Mailing Address - Country:US
Mailing Address - Phone:813-205-8450
Mailing Address - Fax:
Practice Address - Street 1:2935 COUNTY ROAD 193
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1807
Practice Address - Country:US
Practice Address - Phone:727-725-7982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist