Provider Demographics
NPI:1659675395
Name:CLEMENCE, LISA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:CLEMENCE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CARDILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:14450 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5711
Mailing Address - Country:US
Mailing Address - Phone:314-434-6060
Mailing Address - Fax:314-434-6066
Practice Address - Street 1:4020 BUTLER HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1500
Practice Address - Country:US
Practice Address - Phone:314-487-6623
Practice Address - Fax:314-487-6644
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008008297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist