Provider Demographics
NPI:1821123985
Name:THACKERY, LISA (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:THACKERY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 W 77TH TER
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-4730
Mailing Address - Country:US
Mailing Address - Phone:913-341-7585
Mailing Address - Fax:
Practice Address - Street 1:10560 BARKLEY ST
Practice Address - Street 2:SUITE 330
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1811
Practice Address - Country:US
Practice Address - Phone:913-652-9229
Practice Address - Fax:913-652-9198
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist