Provider Demographics
NPI:1871256503
Name:PRUETT, LISA C (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 GLACIAL STREAM LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7665
Mailing Address - Country:US
Mailing Address - Phone:737-529-2496
Mailing Address - Fax:
Practice Address - Street 1:1500 N LAKELINE BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6788
Practice Address - Country:US
Practice Address - Phone:512-817-1842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2136106225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant