Provider Demographics
NPI:1649560657
Name:LAKE, LISA SHIPP (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SHIPP
Last Name:LAKE
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 1:4435 MANGUM DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-2114
Mailing Address - Country:US
Mailing Address - Phone:601-932-0305
Mailing Address - Fax:
Practice Address - Street 1:4435 MANGUM DR
Practice Address - Street 2:SUITE A
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-2114
Practice Address - Country:US
Practice Address - Phone:601-932-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist