Provider Demographics
NPI:1851486211
Name:RADOSA, LISA MARIE (MPT, FAFS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:RADOSA
Suffix:
Gender:F
Credentials:MPT, FAFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1535
Mailing Address - Country:US
Mailing Address - Phone:231-744-0077
Mailing Address - Fax:231-744-0030
Practice Address - Street 1:1400 MERCY DR STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1833
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-5212
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30609OtherBCBS
MI4717630Medicaid
MI30609OtherBCBS