Provider Demographics
NPI:1659505527
Name:WALTON, LISA A (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WALTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:FISHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:18000 COVE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1383
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:
Practice Address - Street 1:18000 COVE ST STE 202
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1383
Practice Address - Country:US
Practice Address - Phone:616-847-1280
Practice Address - Fax:616-847-1290
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931596OtherMEDICARE RAILROAD
IL211082005Medicare PIN
ILP00931596OtherMEDICARE RAILROAD
IL212608002Medicare PIN
IL216860050Medicare PIN
IL205782009Medicare PIN