Provider Demographics
NPI:1740617406
Name:GARLOCK, LISA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GARLOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-4317
Mailing Address - Country:US
Mailing Address - Phone:563-324-1651
Mailing Address - Fax:
Practice Address - Street 1:700 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-4317
Practice Address - Country:US
Practice Address - Phone:563-324-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001225225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant