Provider Demographics
NPI:1801825898
Name:GANNINGER, LISBETH ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISBETH
Middle Name:ANNE
Last Name:GANNINGER
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 1:27 AVENIDA BRIO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6844
Mailing Address - Country:US
Mailing Address - Phone:949-310-3267
Mailing Address - Fax:949-492-1493
Practice Address - Street 1:105 W AVENIDA PICO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4981
Practice Address - Country:US
Practice Address - Phone:949-361-8207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist