Provider Demographics
NPI:1760634802
Name:BANISTER, LISA GAYLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GAYLE
Last Name:BANISTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 ROYALWOOD LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8536
Mailing Address - Country:US
Mailing Address - Phone:580-695-5898
Mailing Address - Fax:
Practice Address - Street 1:880 ROYALWOOD LN
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8536
Practice Address - Country:US
Practice Address - Phone:580-695-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225100000XOtherPHYSICAL THERAPIST