Provider Demographics
NPI:1972557924
Name:WILLIAMS, LISA M (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:636-578-0621
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:2454 W CLAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2548
Practice Address - Country:US
Practice Address - Phone:636-949-3926
Practice Address - Fax:636-949-3928
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO114634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12471565OtherCAQH
MO140380013Medicare PIN
MO164300007Medicare PIN