Provider Demographics
NPI:1902863335
Name:NEWBERRY, LISA GRANTER (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GRANTER
Last Name:NEWBERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 4 MILE RD N
Mailing Address - Street 2:SUITE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-9344
Mailing Address - Country:US
Mailing Address - Phone:231-938-2839
Mailing Address - Fax:231-938-2924
Practice Address - Street 1:3819 4 MILE RD N
Practice Address - Street 2:SUITE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-9344
Practice Address - Country:US
Practice Address - Phone:231-938-2839
Practice Address - Fax:231-938-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist