Provider Demographics
NPI:1972051068
Name:FORD, LISA RAE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:FORD
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 ELK HORN MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3765
Mailing Address - Country:US
Mailing Address - Phone:970-749-4395
Mailing Address - Fax:
Practice Address - Street 1:101 W 11TH ST STE 107
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5108
Practice Address - Country:US
Practice Address - Phone:970-749-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0008879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist