Provider Demographics
NPI:1710434642
Name:COLE, LISA P (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:COLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:300B TEMPLE LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2973
Practice Address - Country:US
Practice Address - Phone:804-524-9036
Practice Address - Fax:804-524-9039
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710434642OtherMEDICAID QMB ONLY
VAC05954OtherMEDICARE GROUP PTAN
VAC05954OtherMEDICARE GROUP PTAN