Provider Demographics
NPI:1740244557
Name:WHITAKER, LISA ANN (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:WEINBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15945
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4054
Mailing Address - Country:US
Mailing Address - Phone:410-729-4508
Mailing Address - Fax:410-729-4526
Practice Address - Street 1:8638 VETERANS HWY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1422
Practice Address - Country:US
Practice Address - Phone:410-729-4508
Practice Address - Fax:410-429-4526
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3884225100000X
MD26130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD502205300Medicaid
MD502205300Medicaid
MD547276ZR1SMedicare PIN