Provider Demographics
NPI:1821405002
Name:OBRYAN, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OBRYAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:FISHER
Mailing Address - State:IL
Mailing Address - Zip Code:61843-0324
Mailing Address - Country:US
Mailing Address - Phone:217-897-1444
Mailing Address - Fax:217-897-1448
Practice Address - Street 1:108 S 3RD ST
Practice Address - Street 2:
Practice Address - City:FISHER
Practice Address - State:IL
Practice Address - Zip Code:61843-9549
Practice Address - Country:US
Practice Address - Phone:217-897-1444
Practice Address - Fax:217-897-1448
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-19
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011821171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor