Provider Demographics
NPI:1821271560
Name:GROSS, LISA K (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:GROSS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 DANIELL CIR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-1980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2909 DANIELL CIR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-1980
Practice Address - Country:US
Practice Address - Phone:123-456-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02460OtherBCBS NEBRASKA
NEP00609476OtherRR MEDICARE